The Role of Resilience and Social Support in Predicting Post-Deployment Adjustment in Navy Personnel

MISSING IMAGE

Material Information

Title:
The Role of Resilience and Social Support in Predicting Post-Deployment Adjustment in Navy Personnel
Physical Description:
1 online resource (169 p.)
Language:
english
Creator:
Cunningham, Craig A
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Nursing Sciences, Nursing
Committee Chair:
Weber, Bryan A
Committee Members:
Lutz, Barbara J
Roberts, Beverly L
Griffin, Wayne D
Hejmanowski, Tracy

Subjects

Subjects / Keywords:
adjustment -- post-deployment -- resilience -- social -- support -- transition
Nursing -- Dissertations, Academic -- UF
Genre:
Nursing Sciences thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
For more than a decade, the U.S. Navy has supported an unprecedented high number of missions fighting the war on terrorism. Thus, well-adjusted personnel who maintain readiness to deploy and carry out these missions are paramount to national security. However, as many as 85% of redeployed service members experience adjustment difficulties in the short-term and 45% of those service members with short-term adjustment difficulties have persistent adjustment problems in the long term. This is a significant problem, since post-deployment adjustment difficulties can severely hamper the general health and wellbeing of service members, thereby, interfering with deployment readiness for future missions. Although little has been reported on post-deployment short-term adjustment, social support, resilience, and characteristics of the transition (e.g. combat, malevolent deployment environments, and additional stressful life events) have been identified as factors that influence long-term adjustment. However, research has only been carried out on service members two or more years after returning from deployment. Given the ongoing uncertainty of world affairs and the necessary readiness for rapid multiple deployments, short-term adjustment may be central to service members' deployment readiness, the Navy's mission, and national security. The purpose of this study was to determine if those factors identified as important for long-term adjustment predicted short-term (12 months or less) adjustment among service members, after deployment; and to examine whether these factors predicted short-term adjustment when controlling for covariates (e.g. Individual Augmentee experience and perceived threat while deployed). One hundred and thirty-two service members between 3 to 6 months post-deployment completed anonymous surveys during a regular clinic visit at a deployment health center. Results of logistic regression indicated that greater resilience and post-deployment social support predicted greater post-deployment adjustment but deployment characteristics were not statistically significant predictors of post-deployment adjustment. Resilience and post-deployment social support remained significant predictors of post-deployment adjustment when controlling for covariates. Resilience and post-deployment social support may be more important than characteristics of the deployment in predicting short-term post-deployment adjustment. Programs that increase resilience and post-deployment social support should be developed and tested.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Craig A Cunningham.
Thesis:
Thesis (Ph.D.)--University of Florida, 2012.
Local:
Adviser: Weber, Bryan A.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-05-31

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2012
System ID:
UFE0044021:00001


This item is only available as the following downloads:


Full Text

PAGE 1

1 THE ROLE OF RESILIENCE AND SOCIAL SUPPORT IN PREDICTING POST DEPLOYMENT ADJUSTMENT IN NAVY PERSONNEL By CRAIG ANDREW CUNNINGHAM A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULF ILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2012

PAGE 2

2 2012 Craig Andrew Cunningham

PAGE 3

3 To the brave men and women of the United States Navy who volunteer to serve this great nation and p preserve, and promote freedom and to my wife and children

PAGE 4

4 ACKNOWLEDGMENTS I thank the Navy personnel who took the time to participate in this study and share their post deployment thoughts and experiences. Th is dissertation would not have been possible without them. I thank Deborah Jones, my new found friend, for her help in coordinating the y sailors and her efforts will never be forgotten. She has surely stored up riches in heaven. I thank my chair and members of my supervisory committee who have generously given their time and expertise to better my work and research skills. I thank Dr. B ryan Weber who invested a tremendous amount of time challenging me, helping me organize my thoughts, and helping me express my though ts in the written word. I especially thank him for his patience, kindness, and sharing of his personal experiences. His s killful approach to break ing the daunting task of completing a dissertation into manageable sections greatly increased my confidence. I thank Dr. Beverly Roberts for helping me learn statistics in the classroom and then applying this knowledge during data analysis. Her guidance helped make data analysis one of the most enjoyable sections to write. I thank Dr. Wayne Griffin who never failed to offer an encouraging word. I treasure the time spent in his class, Trauma & Crisis Intervention, and I conti nue to draw upon the wisdom he shared during our independent study experience. I thank Dr. Tracy Hejmanowski for listening, understanding, and occasionally being my personal counselor. fo r being the type of person I strive to emulate, and for opening her door and her clinic.

PAGE 5

5 This research would not have been possible without her support. I thank Dr. Barbara Lutz for graciously agreeing to join my dissertation committee. I will never for get her patient instruction and guidance in helping me discover and understand my world views. I thank my wife Rhonda for her patience, insightful understanding, and loving support. She was always willing to listen as I expressed my ideas and I consider this to be a vital part of my success. I thank my kids (Jared, Blake, and Alysha) for inspiring me to achieve my goals and for reminding me to laugh. I thank Dad (Gene) and Mom (Betty) for instilling in me the belief that anything is possible with hard work. My family helped me find strength to endure the unanticipated personal and professional challenges that we re experienced during this program. God Bless everyone who contributed to the success of this dissertation. This dissertation was written by C raig Andrew Cunningham while a student at the University of Fl orida studying for a degree in nursing s cience s The views expressed in this dissertation are those of the author and do not reflect the official policy or position of the Department of the Nav y, Department of De fense, nor the U.S. Government. I am a military service member This work was prepared as part of my official duties. Tit Copyright protection under this title is not available for any work o f the United States Government Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of

PAGE 6

6 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 9 LIST OF FIGURES ................................ ................................ ................................ ........ 10 LIST OF ABBREVIATIONS ................................ ................................ ........................... 11 DEFINITION OF TERMS ................................ ................................ .............................. 12 ABSTRACT ................................ ................................ ................................ ................... 15 CHAPTER 1 PROBLEM ................................ ................................ ................................ .............. 17 Post Deployment Adjustment ................................ ................................ ................. 17 Study P urpose ................................ ................................ ................................ ........ 19 Significance to Navy Nursing ................................ ................................ .................. 19 Conceptual Framework ................................ ................................ ........................... 20 Adjustment to Transitions ................................ ................................ ................. 20 Characteristics of the Transition ................................ ................................ ....... 21 Characteristics of the Transition Environment ................................ .................. 21 Characteristics of the Individual ................................ ................................ ........ 22 Research Questions and Hypotheses ................................ ................................ ..... 22 2 LITERATURE REVIEW ................................ ................................ .......................... 25 Deployment Experiences ................................ ................................ ........................ 25 Deployment and Redeployment Preparations ................................ ........................ 27 Deployment Pr eparations ................................ ................................ ................. 27 Redeployment Preparations ................................ ................................ ............. 27 Post deployment Adjustment ................................ ................................ .................. 29 Altered Home Life and Support Network ................................ .......................... 30 Altered Work Li fe and Support Network ................................ ........................... 31 Post deployment Adjustment Assistance ................................ ................................ 32 Resilience, Social Support, and Sojourner Studies ................................ ................. 32 Resilience ................................ ................................ ................................ ......... 33 Social Support ................................ ................................ ................................ .. 34 Sojourner Studies ................................ ................................ ............................. 34 Summary of Problem ................................ ................................ .............................. 35

PAGE 7

7 3 METHODS ................................ ................................ ................................ .............. 37 Study Design ................................ ................................ ................................ .......... 37 Setting ................................ ................................ ................................ ..................... 37 Sample ................................ ................................ ................................ .................... 38 Inclusion Criteria ................................ ................................ ............................... 39 Exclusion Criteria ................................ ................................ ............................. 40 Sample Size ................................ ................................ ................................ ............ 40 Measurement ................................ ................................ ................................ .......... 41 Demogra phic Variables ................................ ................................ .................... 41 Post deployment Adjustment ................................ ................................ ............ 42 Predictor Variables ................................ ................................ ........................... 43 Resilience ................................ ................................ ................................ .. 43 Post deployment social support ................................ ................................ 43 Deployment environment ................................ ................................ ........... 44 Combat exposure ................................ ................................ ....................... 45 Life events ................................ ................................ ................................ .. 45 Covariates ................................ ................................ ................................ ........ 46 Rationale f or covariates ................................ ................................ ............. 46 Covariate measures ................................ ................................ ................... 47 Procedure ................................ ................................ ................................ ............... 47 Recruitment ................................ ................................ ................................ ...... 47 Recruitme nt Support ................................ ................................ ........................ 48 Screening and Recruitment Procedures ................................ ........................... 50 Informed Consent ................................ ................................ ............................. 50 Data Collection ................................ ................................ ................................ 51 Participant Accrual ................................ ................................ ........................... 51 Data Management ................................ ................................ ............................ 52 Data coding ................................ ................................ ................................ 52 Data cleaning ................................ ................................ ............................. 53 Missing data ................................ ................................ ............................... 53 Data entry ................................ ................................ ................................ .. 54 Data Analysis ................................ ................................ ................................ ... 55 Preliminary analysis ................................ ................................ ................... 55 Main analysis ................................ ................................ ............................. 56 Adjusting for covariates ................................ ................................ .............. 57 Protection of Human Subjects ................................ ................................ ................ 58 Assurances ................................ ................................ ................................ ....... 58 Informed Consen t ................................ ................................ ............................. 58 Anonymous Participation and Anonymous Responses ................................ .... 58 Burden and Risk ................................ ................................ ............................... 59 Resources ................................ ................................ ................................ ........ 60 4 RESULTS ................................ ................................ ................................ ............... 65 Participation Accrual Rates ................................ ................................ ..................... 65 Sam ple Representativeness ................................ ................................ ................... 65

PAGE 8

8 Demographic Characteristics ................................ ................................ .................. 66 Preliminary Analysis ................................ ................................ ................................ 66 Missing Values ................................ ................................ ................................ 66 Data Cleaning ................................ ................................ ................................ ... 67 Variable Descriptives ................................ ................................ ........................ 67 Collinearity ................................ ................................ ................................ ........ 70 Main Analysis ................................ ................................ ................................ .......... 70 Adjusting for Covariates ................................ ................................ .......................... 71 5 DISCUSSION ................................ ................................ ................................ ......... 79 Post deployment Adjustment ................................ ................................ .................. 79 Role of Resilience and Post deployment Social Support in Adjustment ................. 80 Characteristics o f the Transition and Adjustment ................................ .................... 82 Other Factors and Post deployment Adjustment ................................ .................... 85 Limitations ................................ ................................ ................................ ............... 86 Strengths ................................ ................................ ................................ ................ 87 Suggestions for Further Study ................................ ................................ ................ 88 Importance of This Work ................................ ................................ ......................... 88 Conclusion ................................ ................................ ................................ .............. 91 APPENDIX A PERMISSIONS AND ENDORSEMENTS OF SCALE MODIFICATIONS ............... 92 B L ETTERS OF SUPPORT ................................ ................................ ....................... 98 C PARTICIPANT STUDY INTRODUCTION INFORMATION SHEET ...................... 101 D SOURCES OF DEPLOYMENT INFORMATION ................................ .................. 102 E MEASUREMENT INSTRUMENTS ................................ ................................ ....... 103 F RECRUITMENT COORDINATOR TRAIN ING MANUAL ................................ ...... 115 G DATA SAFETY MONITORING STUDY RISK ASSESSMENT ............................. 155 H ALTERNATIVE RECRUITMENT STRATEGY ................................ ...................... 156 LIST OF REFERENCES ................................ ................................ ............................. 160 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 169

PAGE 9

9 LIST OF TABLES Table page 3 1 Study variables and measurement ................................ ................................ ..... 61 3 2 Covariates and measurement ................................ ................................ ............. 62 4 1 Study sample representativeness compared to total Navy force structure ......... 73 4 2 Demographic characteristics ................................ ................................ .............. 74 4 3 Military occupation support categories ................................ ............................... 75 4 4 Descriptives of continuous variables ................................ ................................ .. 76 4 5 Covariate and post square and Point biserial correlations ................................ ................................ ............................. 76 4 6 Logistic regression 5 predictor model of post deployment adjustment (N=130)* ................................ ................................ ................................ ............. 77 4 7 Odds ratios for resilience and post deployment social support scores increases and the corresponding odds of post deployment adjustment ............. 77 4 8 Logistic regression 7 predictor model of post deployment adjustment (N=130)* ................................ ................................ ................................ ............. 78

PAGE 10

10 LIST OF FIGURES Fig ure page 1 1 Conceptual model ................................ ................................ ............................... 24 3 1 Participant inclusion/exclusion screening flowsheet ................................ ........... 64

PAGE 11

11 LIST OF ABBREVIATION S D HC Deployment Health Center IA Individual Augmentee ( Service member s who deployed with units other than their own) MOS Military Occupational Specialty NAS JAX Naval Air Station Jacksonville (Florida) OEF Operation Enduring Fr eedom Afghanistan OIF Operation Iraqi Freedom PDHA Post deployment Health Assessment PDHRA Post deployment Health Re assessment

PAGE 12

12 DEFINITION OF TERMS ADJUSTMENT For purposes of this study, adjustment was defined as the human condition in which transi tional experiences have been meaningfully integrated (cognitively and/or behaviorally) by limited career, health, intimate relationship, social relationship, and stress reaction difficulties and few con cerns about th e deployment. Adjustment was measured on the Post Deployment Readjustment Inventory (PDRI). COMBAT EXPERIENCES Combat experiences included exposure to stereotypical warfare experiences such as firing a weapon, being fired on, witnessing i njury and death, and going on special missions that involve d such experiences. Combat experiences were measured on the Combat Experiences subscale of the Deployment Risk and Resilience Inventory (DRRI). DEPLOYMENT Deployment is the relocation of service member s to an operational area. DEPLOYMENT ENVIRONME NT The deployment environment included exposure to events or circumstances representing repeated or day to day irritations and pressures related to life in the war/deployment zone. These personal disc omforts include d the lack of desirable food, uncomfortable climate, cultural difficulties, inadequate equipment, and long workdays. The amount of exposure to a malevolent deployment environment was measured on the Deployment Environment subscale of the De ployment Risk and Resilience Inventory (DRRI). INDIVIDUAL A UGMENTEE An Individual Augmentee is a service member who deploys with a unit other than his/her own unit and sometimes with units in other branches of service.

PAGE 13

13 LIFE EVENTS Life events are sit uations (e.g. death of a spouse, divorce, birth of a child) both positive or negative that have the potential to create stress because they require personal cognitive and/or behavioral adjustment. Life events were measured on the Holmes & Rahe (1967) So cial Readjustment Rating Scale Schedule of Recent Events (SRRS SRE). REDEPLOYMENT Redeployment is the time following a deployment in which service member s return home for reintegration and/or out processing. RESILIENCE Resilience is a process that re sults in the ability to adjust (readjust) to adversity and life circumstances through the attainment of resilient qualities that serve as protective factors against life disruptions and distress (Richardson, 200 2; Walsh, 1996; Rutter, 1985) Resilient qualities are individual characteristics including; 1) the ability to view change/stress as a challenge/opportunity, to remain committed (perseverant), and to recognize limits of situational control, 2) the abilit y to engage the support of others, to maintain close secure attachments, and pursue personal and collective goals acknowledge the strengthening effects of stress and past successes, 4) th e ability to maintain a sense of humor and action oriented problem solving approach, and 5) the ability to remain patient, tolerant of negative affect, and optimistic (Connor & Davidson, 2003; Haglund, Nestadt, Cooper, Southwick, & Charneya, 2007; Southwick, Vythilingam, & Charney, 2005) Resilience was measured on the Connor Davidson Resilience Scale (CD RISC).

PAGE 14

14 SOCIAL SUPPORT Post deployment social support is the perception that family, friends, coworkers, l eaders, and community provides emotional sustenance and instrumental assistance to the service member after returning home. Social support is the establishment and nurturance of a social network that functions by providing supportive others to encourage p erseverance by counteracting feelings of loneliness and providing a sense of safety through the presence of stable, reliable interpersonal connections (Charuvastra & Cloitre, 2008; Haglund et al., 2007) Post deployment social support was measured on the Post Deployment Social Support subscale of the Deployment Risk and Resilience Inventory (DRRI). TENANT COMMAND A tenant command is a unit that is located on a military b ase cha in of command.

PAGE 15

15 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy THE ROLE OF RESILIENCE AND SOCIAL SUPPORT IN PREDICTI NG POST DEPLOYMENT ADJUSTMENT IN NAVY PERSONNEL By Craig Andrew Cunningham May 2012 Chair: Bryan A. Weber Major: Nursing Science s For more than a decade, the U.S. Navy has supported an unpre cedented high number of missions fighting the war o n terrorism Thus, well adjusted personnel who maintain readiness to deploy and carry out these missions are paramount to national security. However, as many as 85% of redeployed service member s experience adjustment difficulties in the short term and 45% of those service member s with short term adjustment difficulties have persistent adjustment problems in the long te rm This is a significant problem, since p ost deployment a djustment difficulties can severely hamper the general health and wellbeing of service memb er s thereby interfering with deployment r eadiness for fut ure missions Although little has been reported on post deployment short term adjustment, social support, resilience, and characteristics of the transition (e.g. combat, malevolent deployment envi ronments, and additional stressful life events) have been identified as factors that influence long term adjustment. However, research has only been carried out on service member s two or more years after returning from deployment. Given the ongoing uncer tainty of world affairs and the necessary readiness for rapid multiple deployments, short term adjustment may be

PAGE 16

16 central to service member loyment readiness national security T he purpose of this study was to determine if tho se factors identified as imp ortant for long term adjustment predict ed short term (12 months or less) adjustment among service member s, after deployment ; and to examine whether these factors predict ed short term adjustment when controlling for covariates (e .g. Individual Augmentee experience and perceived threat while deployed). One hundred and thirty two service member s between 3 to 6 months post deploy ment completed anonymous survey s during a regular clinic visit at a deployment health center. Results of logistic regression indicate d that greater resilience and post deployment social support predicted greater post deployment adjustment but deployment characteristics were not statistically significant predictors of post deployment adjustment. Resilience an d post deployment social support remained significant predictors of post deployment adjustment when controlling for covariates. Resilience and post deployment social support may be more important than characteristics of the deployment in predicting short t erm post deployment adjustment. Programs that increase resilience and post deployment social support should be developed and tested.

PAGE 17

17 CHAPTER 1 PROBLEM Currently, it is estimated that 1.9 million service member s have been deployed to Operations Iraqi Fre edom (OIF) and Operations Enduring Freedom (OEF) in Iraq and Afghanistan (Institute of Medicine, 2010) The deployed personnel regularly faced dangers and/or the perception of threat (i.e. harm to oneself) associated with assignment in hostile territory, i ncluding becoming or witnessing the severely wounded, the dead and dying, and enduring life in malevolent surroundings (Institute of Medicine, 2010; Tanielian, 2008) Readiness m easures for deplo yment included military training that prepared service member s to be hypervigilant, to have instantaneous reactions in times of need, to be on constant high alert, suspicious of everyone outside of their immediate unit, and to suppress their emotions (Cantrell & Dean, 2005; Cantrell & Dean, 2007; Figley & Nash, 2007; Hart, 2000; Ruzek, Schnurr, Vasterling, & Friedman, 2011; Slone & Friedman, 2008) However, no training prepared service member s to alter their pa tterns of behavior and self protective measures (i.e. adjustment) during the transition when they return ed home to the U.S. (Booth Kewley, Larson, Highfill McRoy, Garland, & Gaskin, 2010) Post D eployment Adju stment When deployment ended and service member s returned to the U.S. it was often the first opportunity the troops had deployment life events that they endured, in a thoughtful mann er (Adler, Bliese, McGurk, Hoge, & Castro, 2009; Figley & Nash, 2007; Slone & Friedman, 2008) At the same time they were expected to adjust from a hostile environment and way of thinking and behaving to the saf ety of a homeland environment and way of

PAGE 18

18 thinking and behaving that represented (Figley & Nash, 2007; Slone & Friedman, 2008) It was common for Operation Iraqi Freedom and Operation Enduring Freedom ( OIF/OEF ) military personnel who were low in resilience and low in social support (Pietrzak et al., 2010) to maintain combat or mission oriented thoughts, beliefs, and behaviors (e.g. hypervigilence, emotional suppression, suspicion, avoidance) that negatively impacted their daily routines, sleep, work and interpersonal roles and rel ationships (Bowling & Shermian, 2008; Ruzek et al., 2011) Hence, many were unable to adjust to their secure homeland environment which interfered with their career physical health, i ntimate and social relati onships (Katz, Cojucar, Davenport, Pedram, & Lindl, 2010) To the contrary, service member s who returned from deployment and were high in resilience and who showed a tendency to seek out or construct social su pports were able to make the required homeland transitional adjustment with few difficulties (King, King, Foy, Keane, & Fairbank, 1999; King, King, Vogt, Knight, & Samper, 2006; Pietrzak, Johnson, Goldstein, Mal ley, & Southwick, 2009; Pietrzak et al., 2010; Sharkansky et al., 2000) However, research in the area of post deployment resilience and social support has only been carried out on veterans two or more years after returning from deployment (King et al., 2006; Pietrzak et al., 2009; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995) Thus, the effect of resilience and social support as protective factors against adjustment difficulties is not known among recent ly redeployed service member s ( those who have returned home for reintegration following a deployment).

PAGE 19

19 Study Purpose T he main purpose of this study was to determine if resilience, social support, and characteristics of the transition (e.g. combat exposure, malevolent deployment environment exposure, and additional stressful life events) predict ed short term (12 months or less) adjustment among service member s after deployment. It was hypothesized that service member s with high resilience, high social suppo rt, and low exposure to combat, malevolent deployment environments, and additional stressful life events would have greater post deployment adjustment. The secondary purpose of this study was to examine whether resilience, social support, combat exposure malevolent deployment environments, and additional stressful life events predict ed short term adjustment among service member s after deployment when controlling for Individual Augmentee (IA) experience, military occupational specialty (MOS), gender, mari tal status, number of land based deployments, and perceived threat while deployed. It was hypothesized that service member s with high resilience, high social support, and low exposure to combat, malevolent deployment environments, and additional stressful life events would have greater post deployment adjustment after controlling for Individual Augmentee (IA) experience, military occupational specialty (MOS), gender, marital status, number of land based deployments, and p erceived threat while deployed. Und erstanding factors that predict successful post deployment adjustment is paramount to operational readiness. Significance to Navy Nursing The primary mission of Navy Nursing is to ensure operational readiness of its fighting force. The U S Navy is curr ently the sm allest it has been since World War I

PAGE 20

20 yet it is called upon to respond to more diverse and hostile missions now than at any other time in history. Navy personnel historically supported both sea and ground operations in a variety of wars (e.g. WWI, WWII, Korea, Vietnam, and Gulf War I) as well as responded to natural disasters (e.g. Hurricane Katrina Relief and Earthquake Relief in Greece and Haiti). The ongoing wars in both Iraq and Afghanistan, the additional political instabilities in sever al other world regions (e.g. North Korea, China, and Africa), and the response to simultaneous natural disasters at home and abroad have required a high operational tempo that is unlikely to change in the near future. Thus, t he Navy ng force in order to sustain its high rate of operational deployments (the relocation of forces to operational areas). Those who have redeployed ( returned home for reintegration and/or out processing following a deployment) represent more than 64% of Navy personnel and 40% of the redeployed are currently on their second or greater deployment (Institute of Medicine, 2010; Tanielian, 2008) Thus, the prospect of future and multiple deployments is hi gh making rapid adjustment crucial (Doyle & Peterson, 2005) Identifying protective factors against short term adjustment difficulties and identifying service member s most at risk for adjustment difficulties is central to operational readiness. Conceptual Framework Adjustment to T ransi tions According to Schlossberg (1981) Theory for Analyzing Human Adaptation (Adjustment) to Transition, a transition occurs if a stressful event results in an altered view of self and/or the world that requires a change in behavior and relationships. Th e stress associated with deployment to hostile territory is known to result in an altered

PAGE 21

21 view of self and/or the world (Bragin, 2010) The typical adjustment period to stressful transitions lasts a few months (Bonanno, 2004; Litz, 2007; National Center for PTSD, 2005; Slone & Friedman, 2008) However, service member s with inadequate environ mental and individual resources and characteristics may have difficulty adj usting to the transition (i.e. integrating the necessary behavior and relationship changes into Schlossberg (1981) describes three major factors of transition. They are: 1. charac teristics of the transition (i.e. stressful life events), 2. characte ristics of the environment (e.g. social a nd institutional supports), 3. characteristics of the individual (i.e. resilience). Characteristics of the T ransition Certain life events (e.g. death of a spouse, divorce, birth of a child) and/or the accumulation of multiple events may be a source of stress and vulnerability during the transition time period (Schlossberg, 1981) Moreover, memories and lasting impressions of exposure to combat and malevolent deployment living conditions compound the stress of transition for service member s. Characteristics of the Transition E nvironment Transition env ironment refers to social support systems and the larger institutional support systems (i.e. occupational and c ommunity organizations) to which individuals can turn for help (Schlossberg, 1981) Schlossberg postulates that emotional sustenance and instrumental assi stance gained from social support (e.g. f amily, friends, and peers) provide a sense of safety and counteract lonely feelings by instill ing a sense of belongingness. Institutional support is the availability of resources that aid an individual in meeting transitional demands. Institutional suppo rts are likely similar for active duty service member s redeployed to the same military base.

PAGE 22

22 Characteristics of the I ndividual The third determinant of adjustment to transition is individual characteristics. According to Schlossberg (1981), cognitive and behavioral attributes that confer resilience can promote adjustment during transition. These attributes include an active coping orientation, a sense of situational control, optimism, high initiative, value orientation and commitment, realistic goal setti ng, planful problem solving, and the capacity to enjoy su ccess and learn from failure. Individuals high in resilience often view difficult life events as challenges to be mastered, seek the skills necessary to overcome adversity, are able to maintain emot ional stability, and are not overly distressed by the common reactions to stressful situations. Therefore, characteristics of the transition environment (i.e. social support) and characteristics of the individual (i e. resilience) can serve as protective fact ors during transition. Figure 1 1 transition as it relates to redeployed military service member s. Research Questions and Hypotheses Do Characteristics of the Transition ( combat exposure, malevolent deployme nt environment, and stressful life events), a Characteristic of the Environment (post deployment social support), and a Characteristic of the Individual (res ilience) predict adjustment in Navy personnel redeployed from land based assignm ents? Hypothesis #1a: Service members with high resilience and high social support would have greater post deployment adjustment. Hypothesis #1b: Service members with low exposure to combat, malevolent deployment environments, and additional stressful li fe events would have greater post deployment adjustment.

PAGE 23

23 Do Characteristics of the Transition, a Char acteristic of the Environment, and a Characteristic of the Individual predi ct adjustment in post deployed Navy personnel when controlling for Individual Au gmentee (IA) experience, military occupational specialty (MOS), gender, marital status, number of land based deployments, and perceived threat while deployed? Hypothesis # 2: S ervice member s with high resilience, high social support and low exposure to co mbat, malevolent deployment environments, and additional stressful life events would have greater post deployment adjustment after controlling for Individual Augmentee (IA) experience, military occupational specialty (MOS), gender, marital status, number o f land based deployments, and perceived threat while deployed.

PAGE 24

24 Figure 1 1. Conceptual model

PAGE 25

25 CHAPTER 2 LITERATURE REVIEW Deployment Experiences The attack on the World Trade Center on September 11, 2001 initiated the Global War on Terrorism (GW OT). Since that time, all land based military m issions in foreign countries have been conducted in environments that are considered hostile given the exposure service member s have to combat (Kaylor, King, & King, 1987) malevolent environments (King et al., 1999) and the common per ception that is associated with fighting a war related to the threat to life or limb (Wolfe, Proctor, Davis, Borgos, & Friedman, 1998) Military personnel who deploy in support of these missions do so in one o f two ways, with their units or a s Individual A ugmentees (IA s ) with units other than their own, sometimes in other branches of service. For most, the benefit of deploying und erstand the deployment experience. However, IAs are faced with the additional challenge of developing a support system within their newly assigned unit. Despite how service member s deploy (i.e. with their unit or as IAs), all are required to adjust to h ostile circumstances by remaining focused on the mission and by maintaining hypervigilence. Moreover, basic military warfare training and equipment on which service member s rely provides them with the necessary skills and armament to perform their duties and survive. However, the training and armament includes reminders of constant danger such as locating and killing the enemy, protection from being shot by the use of bullet proof vests, protection from blasts and mortar attacks by the use of Kevlar helme ts and bunkers and loaded weapons that are carried 24 hours a day. Even within the relative safety and security of a U S controlled base

PAGE 26

26 personnel must be ready to fall to the ground when sirens sound signal ing incoming mortar shells manage exposure to enemy prisoners who continue to launch assaults (e.g. physical biting or throwing of human excrement) and protect themselves from the local law enforcement and/or military allies who frequently turn against U.S service members Serv ice member s performing confrontational duties (i.e. combat ants ) and non confrontational duties (e.g. supply technicia ns and medical personnel) in a hostile environment share many of the same experiences and life threatening stressors that include separatio n from family and friends, dangerous environments, continual fear or hypervigilence, and anticipation of the next attack (King, King, Gudanowski, & Vreven, 1995; King et al., 1999; Slone & Friedman, 2008) E xp osure to the dead and severely wounded reinforces the consequences of letting When p roperly trained, the focus on the mission and accompanying hypervigilence becomes embedded in deployed service member is not surprising that upon returning home many service member s experience difficulties adjusting in both the short (within the first 12 months) and long term (greater than 12 months) to a safe non hostile environment and nonthreaten ing homeland way of l ife that seems unfamiliar (Figley & Nash, 2007) There are several reasons for adjustment difficulties that extend beyond suddenly being thrust into an unfamiliar environment, Service m ember s experience redeployment preparations that do not rival preparations for deployment service member s report returning to altered home life, altered work life (e.g. decreased work challenges, an environment lacking activity), altered purpose, and

PAGE 27

27 alte red support networks many of which no longer understand the service member or their experiences (Johnson et al., 1997) Deployment and Redeployment Preparations Deployment P reparation s Basic and pre deploym ent military training is competency based and a continual part of the military life with multiple weeks to months of intensive training upon enlistment, upon assignment to a specific military occupation, and immediately prior to a deployment (Adler, Bliese, & Castro, 2011; Cantrell & Dean, 2005; Cantrell & Dean, 2007; Figley & Nash, 2007; Hart, 2000; Institute of Medicine, 2010; Ruzek et al., 2011) Training includes use of weaponry, proper fitting and use of p ersonal protective equipment designed for the anticipated hostile and threatening environmental exposures (e.g. climates, harmful chemicals, biological and environmental agents, and the type of weapons and tactics that the enemy will likely use), local cus toms, and disease vectors common to the deployed location, basic medical first aid, and how to recognize a stress reaction in a comrade. In addition, role playing in simulated and stressful situations that resemble the deployment environment are frequentl y used to promote skill development. Practice proceeds until service member s can respond instinctively and display a competency for performing the necessary skills with a focus on completing the assigned mission driven task. Redeployment P reparation s Rede ployment training varies with each branch of the service but is largely psycho educational and involves sharing of information related to manifestations of adjustment difficulties and where to go for assistance (Institute of Medicine, 2010; Martin, 2007; National Center for PTSD, 2005; Ruzek et al., 2011; Slone & Friedman,

PAGE 28

28 2008) Computer based mo dules and instructor led lectures are common strategies for this type of training. Redeployment training, which oft en occurs in the deployment theatre (while service member s are still confronted with hostile circumstances) and during the early redeployment time period (i.e. first month after returning home), is tailored to provide information designed to aid the redepl oyed service member to predict potential challenges during reintegration (Adler et al., 2011; Martin, 2007) However, competency based training that service member s receive in prep aration for deployment and the preparation for redeployment are vastly different in comparison. Redeployment preparation does not include the same type or level of preparation (Adler et al., 2011; Bowling & She rmian, 2008; Institute of Medicine, 2010; Ruzek et al., 2011) For example, the breadth and depth of the curriculum and simulation of redeployment stressors is not provided to service member s. Thus, developing the skills necessary to adjust successfully to redeployment is not structured the same as deployment etc. are not readily available. There are individu al differences in how service member s use the information provided to them related to redeployment adjustment (Institute of Medicine, 2010; Litz & Roemer, 1996; Litz, 2007; Litz, 2004) For individuals high in resilience, information about what to expect during redeployment may be sufficient as these individuals likely use this information in order to develop the necessary skills for dealing with reintegration challenges. H owever, informational support may not be as effective for service member s low in resilience and without the social support found to be effective in

PAGE 29

29 facilitating adjustment (Sayers, Farrow, Ross, & Oslin, 2009; Shea, Vujanovic, Mansfield, Sevin, & L iu, 2010) Post deployment A djustment Post deployment adjustment refers to the condition in which transitional related to career, health, intimate and other social relatio nships, and absence of stress reactions associated with preoccupying concerns about the deployment (Bowling & Shermian, 2008; Katz et al., 2010; Slone & Friedman, 2008) Learning to adjust to changes in health status, household and work roles, and relationship expectations is not easy because it requires the service member to incorporate new knowledge or place within a social network (Meleis, 2007) Aberrations in adjustment occur when service member s have difficulty making the redeployment transition and have persistent hypervigilence, constriction of em otion, and difficulty reestablishing social connections. As many as 85% (Shea et al., 2010) of redeployed service member s experience adjustment difficulties in one or more personal or professional areas in the short term and 45% of those service member s with short term adjustment difficulties have persistent adjustment problems in the long term (i.e. greater than 42 months) (Sayer et al., 2010) The inherent signifi cance of adjustment difficulties is the profound and negative effect it has on relationships, productivity, and the ability and readiness to carry deployment adjustment requires redefining family and work roles and expectatio ns, renegotiating division of labor, recreating intimacy, and attempting to create shared meaning of the experience with loved ones and comrades who did not deploy (Bowling & Shermian, 2008)

PAGE 30

30 Altered Home Lif e and Support N etwork One of the greatest challenges reported by redeployed service member s is an altered home life (Doyle & Peterson, 2005) Redeployed service member s indicate they feel like guests in their own home (Sayers, Farrow, Ross, & Oslin, 2009) This guest like perception may be due to changes (alterations) that took place in the service member (Brenner et al., 2008; Gambardella, 2008; Sl one & Friedman, 2008) For example, deployed service member s who married shortly prior to deployment and/or left a pregnant wife behind (a common occurrence) may have missed the birth of children, still others were absent for family traumas and triumphs and other life events that could only partially be shared through phone, email, or written letters (Doyle & Peterson, 2005; Johnson et al., 1997; Yerkes & Holloway, 1996) Some service member s return to marria ges that do not survive deployment and they face marital separation/divorce. Another common occurrence is the return to marriages and/or family situations in which service member s feel less valuable and unsure about their family roles, since the family se emed to get along fine in the service member s absence while deployed. In these situations, parents, spouses, siblings, children, significant others, and close friends assumed responsibilities that were previously performed by the deployed service member When the redeployed service member exerts a claim to prior responsibilities, those who assumed the added responsibilities are often left feeling that their efforts during deployment are devalued or they may be reluctant to relinquish the role they found to be rewarding and boosting to their self esteem (Doyle & Peterson, 2005; Gambardella, 2008) In contrast, other spouses expect the redeployed service member to resume their prior responsibilities and roles i mmediately upon returning which can be

PAGE 31

31 overwhelming given the often linear simplified nature of deployment life (Slone & Friedman, 2008) All of these scenarios reflect incongruence between the service member and their social network. The incongruence can lead to feelings of misunderstanding and resentment interfere with reestablishment of intimacy and trust, and create or lead to social isolation (Brenner et al., 2008) Altered Work Life and Support N etwork During the service member s absence, changes likely took place in the military home base work environment, since non deployed personnel continued to move (i.e. permanent cha nge in station [PCS]) from one base to another which occurs even during war time. C ommands come under new leadership as commanding officers and unit (department) leader s are reassigned, equipment is constantly updated and changed, and personnel are chan ged as a result of regular PCS moves and rolling deployments. Hence, it is common for the returning service member to find a stranger performing the duties (s)he once performed. Thus, the redeployed service member is faced with meeting new people, having to adjust to new and unfamiliar role s and perhaps navigating a new working environment. Adjusting to the altered home based work environment is further complicated for service member s who deployed as Individual Augmentees. Individual Augmentees typica lly redeploy alone back to their parent command without the presence of supportive comrades who shared the same deployment experiences which can interfere with the closeness and bonds that service member s have with each other (Blais, Thompson, & McCreary, 2009; Charuvastra & Cloitre, 2008; Figley & Nash, 2007; Guay, Billette, & Marchand, 2006) Divergent deployment experiences may result in

PAGE 32

32 fewer sources of post deployment sup port from comrades and contribute t o a belief that no one understands or appreciates what the service member has experienced. Post deployment Adjustment Assistance Current interventions to aid with redeployment adjustment include 1) screening s to identify those who have psychopathological adjustm ent problems (e.g. PTSD, Major D epression) and referring them to medical and behavioral health specialists (e.g. psychiatrists, psychologists, social workers, psychiatric nurses) (Martin, 2007) 2) s elf referral resources such as Military One S ource which coordinates and provides individual and family counseling, 3) self help pro grams (e.g. Vet 4 Vet groups, Vets Prevail online support group), and 4) more recent prevention efforts t hat include programs such as Navy Operational Stress Control (OSC) (Ruzek et al., 2011) The OSC pr ogram is grounded in promoting self care (e.g. good sleep, fitness, eating habits, maintaining a sense of humor, positive attitude and social connections), and early detection of stre ss reactions in fellow comrades. It includes an implied duty of each serv ice member to encourage their stress reacting comrade to seek appropriate care (Ruzek et al., 2011) The OSC program is believed to contribute to resilience building (Bowles & Bates, 2010) among S ailors and Marines by providing informational support However, it was not designed to predict which service member s will eng age in good self care practices and the re is no empirical evidence to date that suggests resilience is related to short term post deployment adjustment despite its relationship to long term adjustment. Resilience, Social Support and Sojourner Studies Post deployment adjustment involves succes sful adaptation and positive functioning in meeting challenges and responding to changes in a social environment.

PAGE 33

33 Most current knowledge on the topic of the adjustment process comes from studies conducted on post deployed military populations two or more years after redeployment and, thus, describes adjustment in the long term (King et al., 1999; King, Taft, King, Hammond, & Stone, 2006; King et al., 2006; Waysman, Schwarzwald, & Solomon, 2001) Service member s with long term adjustment difficulties tend to be low in resilience, have had high exposure to combat, malevolent deployment living conditions and/or additional stressful life events and have inadequate social supports (Kessler et al., 1995; King et al., 2006; Pietrzak et al., 2009; Pietrzak et al., 2010; Sharkansky et al., 2000) Pietrzak and colleagues (2009) postulate that long term post deployment adjustment is related to and can be predicted by resilien ce and social support. Others hypothesize that resilience and social support may also play a significant role in how a person adjusts in the short term (Charuvastra & Cloitre, 2008; Haglund et al., 2007) Re silience Resilience represents the personal qualities that enable one to adjust to life circumstances such as personal competence, high standards, and tenacity, tolerance of negative affect and viewing stress as strengthening, positive acceptance of chang es, personal control, and spiritual orientation to the future (Connor & Davidson, 2003; Richardson, 2002) Individuals high in resilience tend to view difficult life events, such as adjusting during redeployme nt, as challenges to be mastered. Consequently, individuals high in resilience seek the skills necessary to overcome adversity, believe that they can elicit control over difficult situations (i.e. have choices), are able to maintain emotional stability, a nd are not overly distressed by common reactions to stressful situations (e.g. reexperiencing, intrusive thoughts, hyperarousal) (Connor & Davidson, 2003; Richardson, 2002) Thus, highly resilient service memb er s would be

PAGE 34

34 expected to have the necessary skills for dealing with current and future life stressors and be quick to adjust. Social Support According to King et al (2006), socially supportive factors include having someone available with whom to talk, f eeling understood and appreciated by others, and having others available to provide practical assistance. Having these supportive factors in place was shown to be a protective factor against long term post deployment adjustment difficulties in Vietnam Vet erans (King et al., 1999) Gulf War Veterans (King et al., 2006) prisoners of war (Engdahl, Dikel, Eberly, & Blank, 1997) United Nations S oldiers (Kaspersen, Matthiesen, & Gotestam, 2003) and Operation Enduring Freedom and Operation Iraqi F reedom Veterans (Pietrzak et al., 2009) Service member s who had returned from deployments to Iraq and Afghanistan two years earlier who endorsed adequate social support reported significantly fewer long term adjustment difficulties (e.g. problems at work, family problems, and problems with friends and peers). However, little is known about the effect of social support and how it relates to short term adjustment among recently redeployed service member s (Blais et al., 2009; Bowling & Shermian, 2008; Katz et al., 2010; MacDermid Wadsworth, 2010) Sojourner S tudies Since little is written on the positive effects of resilience and social support on short term redeploym ent adjustment, a review of Sojourner studies was conducted. Consistent with redeployed service member s, many Sojourners indicate that the (Furukawa, 1997) and that as many as 70% of repatriates experience significant s hort term adjustment difficulties (Black, Gregersen, & Mendenhall, 1992) The process of rep atriation

PAGE 35

35 adjustment can cause arousal, stress, trouble concentrating, irritability, and anxiety (Stringham, 1993; Sussman, 2000) However, as hypothesized among redeployed service member s, repatriated Sojourn ers who are high in resilience and have adequate social supports tend to adjust well in the short term and report few work and interpersonal adjustment difficulties (Herman & Tetrick, 2009; Sussman, 2001; Sussma n, 2002; Szkudlarek, 2010) The Sojourner literature adds to the argument that adjustment can be a source of stress and that resilient qualities and adequate social support are related to fewer short term adjustment difficulties. Summary of Problem Ser vice member s commonly experience short term redeployment adjustment difficulties during redeployment transition (Shea et al., 2010) and little is known about the process of redeployment short term adjustment (Blais et al., 2009; Bowling & Shermian, 2008; Katz et al., 2010; MacDermid Wadsworth, 2010) There is evidence that redeployment adjustment difficulties in the short term may progress to adjustment difficulties in the long term that can severely interfere with and hamper the general health and wellbeing of service member s (Bryant, 2003; Sayer et al., 2010; Sayers et al., 2009; Thompson et al., 2004) and their readine ss to deploy in support of future missions. Most research related to redeployment adjustment from the Global War on Terrorism (GWOT) h as been conducted primarily on A rmy personnel (Hoge et al., 2004; Milliken, Auchterlonie, & Hoge, 2007) and focused on identifying those with PTSD or other psychiatric problems and may not generalize to other branches of service or to those service member s experiencing adjustment difficulties bu t who do not have PTSD. No redepl oyment adjustment stud ies were located that focus on Navy personnel without PTSD even though redeployed service member s without PTSD experience problems

PAGE 36

36 related to social relations hips and social and vocational engagement and productivity (Sayer et al., 2010)

PAGE 37

37 CHAPTER 3 METHODS Study Design This descriptive study used a cross sectional design to determine if resilience, social support, and transition characteristics (e.g. combat exposure, malevolent deployme n t environments, and/or additional stressful life events) predict short term psychosocial adjustment in post deployed service member s. The results of this study were expected to provide evidence on which future interventions can be based to assist service member s adjust to the psychosocial demands after returning from deployment. Setting Naval Air Station Jacksonville (NAS JAX) is a multi mission base that houses the fourth largest naval h ospital in the U.S., and hosts the operations of m ore than 100 tenan t commands, e ach with its own reporting structure. These independent reporting structures along with deployment cycles that change in response to mission demands make it difficult to know the exact number of service member s deployed at any given time. Ho wever, an estimated total of 2,400 service member s from NAS JAX report to the Naval Hospital Branch Health Clinic annually prior to deploying to hostile conditions and/or territories including Iraq, Afghanist an, Djibouti, and Cuba Although a small number of r edeployed service member s move to another base soon after returning from deployment, most service member s who were deployed from NAS JAX redeploy back to NAS JAX. Upon redeployment, service member s are required to undergo physical and mental health sc reening by completing the post deployment health assessment (PDHA) and the post deployment h ealt h re a ssessment (PDHRA) (Martin, 2007; Rona, Hyams,

PAGE 38

38 & Wessely, 2005) Although flight surgeons provide these scre enings in the field for personnel assigned to their unit, approximately 200 service member s each month receive their psychological screenings through the NAS JAX Deployment Health Center (DHC) (a t raditional medical clinic located in the Branch Health Clin ic). The DHC conducts these screenings for service member s redeployed from land based operations. Shipboard post deployment health screenings are conducted through a different venue. The sample in this study were service member s recruited from the DHC a t NAS JAX at the conclusion of the health screening that took place 90 to 180 days after redeployment. Sample Representativeness of the sample was based on the Institute of Medicine Report (2010) that indicated service member s deployed (e.g to OIF/OEF) a re representative of the total Navy force structure. According to the most recent Institute of Medicine Report, 89 % of t hose deploye d to OIF/OEF are male, 66% are w hit e, 16% b lack, 10% Hispanic, 4% A sian, and 4% other. The current demo graphic characteris tics of the Navy consists of 88% enlisted, with 65% of the enlisted between the ages of 20 29 and 12% officer, the majority of whom are between the ages o f 25 39. Approximately 55% of Navy personnel are married and 42.5% have children. The way in which se rvice member s adjust during redeployment may vary based on hostile/combat exposure and sources of support while deployed. Given the diversity of the tenant commands housed at NAS JAX, Navy personnel stationed there serve in varied military occupational sp ecialties (MOS). Participants in this study were assigned to a number of MOS that ranged from non confrontational duties (e.g. cooks, el ectronics technicians, store keepers) to aviators (e.g. pilots and flight crew personnel)

PAGE 39

39 and medical occupations (e. g. corpsmen, nurses, doctors). Thus, exposure to hostile/combat situations and environments was expected to vary among participants, which may have had a profound effect on redeploym ent adjustment. Moreover, it was common (dur ing the current conflicts) f or n aval personnel to deploy and re deploy as Individual Augmentees in the absence of comrades who shared the same deployment experiences. Despite the diversity of MOS or deployment experience as an IA, redeployment was expected to be a source of stress for service member s. Therefore, all service member s redeployed to NAS JAX who met inclusion criteria were eligible to participate in this study. Da ta was collected and analyzed to d etermine if MOS or IA status had an effect on study outcomes. Inclusion Criteria Since service member s were required to complete their PDHRA between 90 and 180 days after redeployment, all active duty redeployed Navy personnel reporting to NAS JAX DHC for completion of their PDHRA were eligible to participate in the study. Th e population was selected since they were recently e xposed to the stressors of land based deployment operations and they faced the short term psychological adjustment demands of reintegration for which little is known. Service member s completing their in itial 30 day post deployment health assessment were not selected because months reintegration which was reported to interfere with participation and/or accurate reporting (i.e. failing to report or acknowledge difficulties because of a preoccupation with reuniting efforts with family and friends) (Hoge et al., 2004; Slone & Friedman, 2008)

PAGE 40

40 Exclusion Criteria Redeployed Navy personne l who receive their post deployment health screenings at the DHC are those who have not suffered major physical injuries (i.e. amputations) or terminal illnesses and those who do not have current diagnosis of mental illness that would interfere with their ability to perform their assigned duties. For example, Navy personnel who suffer ed amputations, terminal illnesses, severe PTSD, or who were at ris k of harm to self or others would have received their physical and psychological care directly through inpat ient hospital facilities (e.g. Naval Medical Center Portsmouth, National Naval Medical Center in D.C., and Balboa Naval Hospital in San Diego). However, Navy personnel receiving their post deployment health screenings at the DHC may have had undiagnosed P TSD, or traumatic brain injury and may have be en experiencing new onset risk of harm to self or others all of which may have confound ed study outcomes since these conditions will profoundly affect adjustment. Thus, th e exclusionary criteria were as fo llows : 1. Service members who s creened positive on the Posttraumatic Stress Disorder Checklist Military Version (PCL M) (Bliese et al., 2008) for probable PTSD/probable TBI Since both TBI and PTSD are defined in large part by the same self reported symptoms (Hill, Mobo, & Cullen, 2009) the PCL M was used to screen for probable PTSD and probable TBI. The PCL M is part of the 90 to 180 day post deployment health reassessment (PDH RA) interview conducted by the Navy at the DHC. Data from the PDHRA data collection form was reviewed to determine service member s eli gibilit y for this study and for the other exclusionary criteria Using data collected by the Navy to determine eligibility for this study was expected to minimize study related participant burden. 2. Service members i dentified as posing a current risk of harm to s elf or others during the post deployment health re assessment interview. Sample Size There is limited information about the relationship between resilience and post deployment adjustment and between social support and post deployment adjustment in

PAGE 41

41 militar y populations. However, Pietrzak et al. (2010) reported the moderate to strong relationships between resilience and post deployment adjustment to be (r = .40) and social support and post deployment adjustment (r = .53), explaining 16% and 28% of varianc e outcomes, respective ly. According to Field (2006) and Meyers et al. (2006) these relationships represent medium to large effect sizes. G*Power 3.1.2 (Erdfelder, Faul, & Buchner, 1996; Faul, Erdfelder, Lang, & Buchner, 2007; Faul, Erdfelder, Buchner, & Lang, 2009) was used to calculate the sample size for a fixed linear multiple regression model (R2 deviation from zero) with 11 predictors (5 main predictors resilience, social support, malevolent deployment environment, combat exposure, stressful life events and 6 control predict ors Individual Augmentee experience, milit ary occupational specialty gender, marital status, number of land based deployments, and perceived threat while deployed) for this study. Conservatively using a medium effect participants was needed for adequate power. Measurement Demographic Variables (Permission to use copyright material was obtained and letters of permission appear in Ap pendix A) ( Table 3 1). A 13 item investigator developed questionnaire was used to assess demographic data including age, gender, rank, education, ethnicity, military occupation, marital status, number of land based deployments, length of most recent deplo yment, and the presence of an IA experience. Respondents were asked to provide responses related to their military service and their personal background. Items on the demographic questionnaire were based on Department of Defense (Martin, 2007; Rona, et a l., 2005) post deployment health assessment (PDHA) and post

PAGE 42

42 deployment health reassessment (PDHRA) screening surveys. The measure was expected to take 1 to 2 minutes to complete. Post deployment Adjustment The Post deployment Readjustment Inventory (PDRI ) is a 36 item self report measure on which respondents rated their agreement with how true were the items in 6 domains of functioning since returning from deployment (Career, Health, Intimate Relationships, Social readjustment, Concerns about deployment, and Stress symptoms). Items were rated on a 5 point Likert scale from 1 item s were reverse scored and summed for a total score that could range from 36 to 180 with higher scores indicating greater post deployment adjust ment. The PDRI was validated among a diverse sample of post deployed men and = .97). Convergent validity with other measures of psychosocial adjustment difficulties was established (e.g. posttraumatic s tress disorder inventory, PCL M, r = .90 and the Brief symptom inventory, r = .82 ) (Katz et al., 2010) the sample population of active duty military personnel. The original developer of the scale endorsed the use of the new wording (Appendix A). The instrument effectively measured patterns of readjustment difficulties for veterans who did not meet criteria for PTSD (Katz et al., 2010) Post hoc item analysis was used to compare the modified on the PDRI items was .961. The measure was expected to take approximately 5 minutes to complete.

PAGE 43

43 Predictor Variables Resilience The Connor Davidson Resilience Scale (CD RISC 25) (Connor & Davidson, 2003) was used to measure resilience. The CD RISC 25 is a 25 item inventory of resiliency characteristics or qualities across 1 7 domains of functioning (e.g. commitment, recognition of limits of control, viewing stress/change as a challenge/opportunity, tolerance of negative affect, etc.) Items were scored on a 5 point Likert scale from 0 respondents felt over the past month. Item scores were summed to yield a total score that could range from 0 to 100 with higher scores indicating greater resilience. Pietrzak et al. (2009) validated the CD RISC 2 5 with a diverse sample of post deployed men and on the CD RISC 25 items was .931. The measure was expected to take approximately 4 minutes to complete. Post deploym ent social s upport The Post deployment Social Support Scale (PSSS) is a 15 item self report measure that assesses post deployment emotional support and instrumental assistance provided by family, friends, coworkers, employers, and community (King et al., 2006) Respondents indic ated how much they agreed or disagreed with a set of statements related to social support after deployment. Items were rated on a 5 point Likert scale with responses that ranged from 1 was modified from service member relevant to an active duty population. The original developers of this scale endorsed the

PAGE 44

44 use of the new wording and think that it captures the intent of the construct being measured (Appendix A). Item scores were summed (reverse scoring items 6 & 8) and could range from 15 to 75 with higher scores indicating greater social support upon return from deploymen t. The measure was validated with OIF, OEF, and Gulf War veterans (King et al., 2006; Pietrzak et al., 2009; Vogt, Proctor, King, King, & Vasterling, 2008) eported responses to the PSSS were negatively related to measures of adjustment disorders and physical symptoms and were positively related to measures of physical, mental, and cognitive functioning. on the PSSS items was .891. The measure was expected to take 2 to 3 minutes to complete. Deploymen t e nvironment The Deployment Environment is a 20 item self report measure that assesses exposure to events or circumstances representing repeated or day to day irritations and pressure s related to life in the war zone (e.g. lack of desirable food, lack of privacy, poor living arrangements, uncomfortable climate, cultural difficulties, boredom, inadequate equipment, and long workdays) (King et al., 2006) Respondents indicated their extent of exposure (over th e course of their entire deployment) on a 5 point Likert scale that ranged from 1 summed (reverse scoring items 3, 4, 7, 8, 10, 12, 13, 17, & 19) for a total score that could range from 20 to 100 with higher scores indicating greater exposure to difficult living and working environments. King (2006) reported the measure was moderately correlated with measures of psychosocial adjustment distress (e.g PTSD r = .36, depression r = .30 & Anxiety r = .37) and has good reliability ( = .89 ). In this sample,

PAGE 45

45 on the Deployment Environment items was .872. The measure was expected to take 2 to 3 minutes to complete. Combat e xposure The Combat Experiences Scale Modified (CES M) is a 15 item self report measure that assesses exposure to combat (e.g. firing a weapon and witnessing injury and death) and was used to measure another characteristic of the deployment environment (King et a l., 2006; Vogt et al., 2008) Respondents indicated what amount of time they were exposed to combat conditions on a 5 point Likert scale that ranged from 1 that could range from 15 to 75 with higher scores indicating greater frequency of combat exposure. Vogt et al. (2008) reported the CES on the CES M items was .903. The measure was expected to take 2 to 3 minu tes to complete. Life e vents The Social Readjustment Rating Scale Schedule of Recent Experiences ( SRRS SRE) is a 43 item self report measure that assesses exposure to life events that are commonly reported as stressful and that also require personal adj ustment (Holmes & Rahe, 1967) Respondents were pre sented wi th a list of life events and were asked to indicate (by circling) which events occurred in the last 12 months. Each item had a weighted score that represents the relative level or degree of change required. Weighted scores from all circled items were s ummed for a total score that could range from 0 to 1466 with higher scores indicating greater exposure to stressful life events that require personal change. Hobson (1998) and Hobson (2001) have validated the measure in large national samples and c onsensus on the content listing of events and

PAGE 46

46 the relative order and magnitude of the means of items is reported to be high as 0.4777 (p<0.0005) for discrete groups (e.g. male, female, single, married, age groupings education level soc ial class, religion, generation, and Navy personnel) (Holmes & Rahe, 1967; Rahe, Mahan, & Arthur, 1970; Scully, Tosi, & Banning, 2000) The test retes t reliability coefficient in a military sample o f Vietnam V eterans has been reported to be .85 (Watson et al., 1993) Additionally, Rahe et al. (1980) compared a group of Navy personnel from 1977 with a demogr aphically matched group of men from the original 1967 study and reported Spearman rank order correlation between the mean rankings of the items to be .85 (p<.001). The measure was expected to take 2 minutes to complete. Covariates Rationale for c ovariates Service member characteristics may not be comparable among partic ipants and these differences were unavoidable given the convenience sampling strategy employed in this study. Thu s, additional covariates were measured and accounted for in the regression e quation to control for rival explanations of observed relationships and to reduce error variance of the independent variables on the study outcome that may have influence d post deployment transitional adjustme nt. The covariates that were measured were sel ected because they represent factors tha t from a military standpoint were likely to be an added source of stress (Blais, Thompson, & McCreary, 2009; Charavastra & Cloitre, 2008; Figley & Nash, 2007; King et al., 2006; Street, Vogt, & Dutra, 2009; Litz, Fig ley & Nash, 2007;National Center for PTSD, 2008; Tannelien 2008 ;Vasterling, 2010) and included Individual Augmentee status military occupational

PAGE 47

47 specialty gender, marital status, number of land based deployments, and perceived threat while deployed. Cova riate m easures Individual Augment ee experience and gender were recorded as dichotomous va riables. Marital status was recorded as a discrete numer ical value that represented how participants classified themselves at t he time of data collection ( Table 3 2). Militar y occupational specialty was recorded as a discrete numerical value that corresponded to the Navy classification of military occupation al specialties It was anticipated that there would be approximately six MOS identified given the characteris tics of personnel who typically complete their redeployment screening at the Deployment Health Center Naval Air Station Jacksonville. The number of land base d deployments was recorded as continuous data and perceiv ed threat while deployed was measured usi ng a single modified item extracted from the Deployment Risk and Resiliency Invento ry (King et al., 2006) that asked participants to indicate on a 5 point Likert scale from 1 moments during deployment when I thought/felt I was in great danger of being wounded Many see being in danger as simply part of the job. Thus, the item was m odified in such a manner that was believed to give permission to part icipants to normalize even passing experiences of perceived threat. Procedure Recruitment Service member s returning from deployment were required to undergo military physical and psychological screening at two tim e points (within 30 days and 90 to 180 da ys). The study sample was recruited from the DHC when service member s report ed

PAGE 48

48 to complete the second of these two required post deployment health screenings. This time point and venue was selected for several reasons. The first reason relates to the ti ming of the post deployment health reassessment screening that coincides with the time point when readjustment concerns begin to emerge at higher rates three to six months after deployment (Milliken et al., 2007 ) Second, recruiting pa rticipants from the DHC provided 1) a centralized location t o access the post deployed Navy personnel assigned to the various tenant commands, 2) a location where service member s expect ed to discuss physical and behavioral health needs, 3) reduced risk to participants by integrating study procedures into routine screening procedures already being performed at the DHC, 4) medical and beh avioral health resources in close proximity in the unlikely event a participant had untoward reac tion to study participati on, and 5) a location where service member s did not have competi ng work demands All active duty Navy personnel completing their post deployment health reassessment were eligible for screening and inclusion in this study. Theref ore, the demographic characteristics of the sample population were expected to include gender and minority representation that approximated the demographic characteristics of post deployed Navy personnel at NAS JAX (e.g. 89% male, 66% white, 16% b lack, 10% Hispanic, 4% Asian, and 4% other). Recruitment S upport Letters of support were obtained from the Division O fficer of the Jacksonville Naval Hospital Branch Health Clinics, the Department Head of the DHC, the Deployment Health Psychologist and Program Mana ger at the DHC, and the Physician Assistant (PA) responsible for conducting the PDHRAs (Appendix B Letters of Support). A waive r of HIPAA authorization was obtained from the University of Florida and the U S

PAGE 49

49 Navy to review medical records necessary to deter mine those service member s who m et study inclusion/exclusion screening criteria. The DHC Physician Assistant responsible for conducting the PDHRA interview agreed to be the recruitment coordinator for this study ( Appendix B). The recruitment coordi nator was trained to screen, recruit, and administer the study survey, thus blinding the investigator to the identity of participants and making this an anonymous survey. The recruitment coordinator had participated in conducting research at other medical treatment facilities and was familiar with the conduct of research in clinical settings. The recruitment coordinator was not a military service member thus enhancing study protocol fidelity that was maximized since relocation of this person was unlikely during the study period. In the unlikely event the recruitment coordinator was no longer employed at the DHC, the Deployment Health Psychologist and Program Manager (who was also not a military service member and unlikely to relocate during the study per iod) agreed to support the utilization of another DHC staff mem ber as a recruitment coordinator ( Appendix B). The advantages to utilizing the DHC staff as the recruitment coordinator included efficiency, minimizing disruption of the post deployment scree ning process, and the ability for participants to remain anonymous to the investigator. Anonymity has been shown to increase research study participation in adult populations surveyed while waiting for clinic appointments (McPherson & Schwenka, 2004) during hospital admissions (Haas & Pazdernik, 2006) among military personnel during training (Trent, Stander, Thomsen, & Merrill, 2007) and among mi litary personnel during the post deployment readjustment period (Wright et al., 2005)

PAGE 50

50 Screening and Recruitment P rocedures Screening for inclu sion in the study and recruitment took place at the conclusion of the Navy mandated physical and psychologic al screening interview, which was recorded on DD FORM 2900 (PDHRA) and supplemented with the PCL M form at the DHC. Responses on DD FORM 2900 and t he PCL M provided the interviewer with the necessary information to screen participants for study inclusion/exclusion. The recruitment coordinator (PA) viewed the forms but did not extract data to minimize the effort of the recruitment coordinator so as n ot to impact on her ability to complete her regular mission of identifying the physical and mental health needs of service member s and referring them as necessary. Since the PA reviewed the information on the 2900 and the PCL M as part of the PDHRA interv iew, the amount of additional time to screen and recruit for study inclusion was expected to average between 2 to 3 minutes per participant. The recruitment coordinator used the Participant Inclusion/Exclusion Screening Flow Sheet (Figure 3 1) to guide de cisions on which service member s met study inclusion/exclusion criteria. Service members who were excluded (e.g. those with probable PTSD and those identified as a current risk of harm to self or others) were referred for appropriate care per normal post deployment screening procedures. Recruiting service member s using this method was expected to lead to a representative sample of the target population and to recruit service member s who met study inclusion/exclusion criteria (Butterfield, Yates, Rogers, & Healow, 2003) Informed Consent All service member s who met inclusion criteria were provided with the participant information sheet (Appendix C) that contained a written descriptio n of the study including the study purpose, procedures, duration, risks, benefits, and the right to

PAGE 51

51 withdraw at any time without penalty. They were also provided a list of deployment related resources (Appendix D), and a study packet that contained the st udy questionnaires (Appendix E ). The recruitment coordinator was trained to respond to service member available to the recruitment coordinator should there have been a question or concern that could not be addressed Completing and returning the study questionnaires serve d as documentation of implied informed consent. Data Collection Once all questions and concerns were addressed, the recruitment coordinator escorted participants to a room tha t afforded privacy and showed them where to place the study packet when completed. Participants could then decide to complete the study packet or not complete the study packet and placed either the completed or the non completed forms in the locked file c abinet. The investigator collected completed surveys from the file cabinet at the end of each data collection day. This process continue d until 123 participants who me t inclusion criteria completed the survey. Participant A ccrual It was difficult to est imate participation rates in this population. However, the typical response rate for similar mailed surveys in Navy personnel is about 17% (Woodruff & Conway, 1994) In this study, special efforts were employed such as face to face recruitment which has resulted in participation rates of 59% (Newby et al., 2005) to 93% (Katz et al., 2010) However, due to the wide range of reported participation rates, a conservative 59% participation rate was used to estimate partici pation rates in this study ( Table 3 3 ). Thus, it was estimated that it would take ap proximately 3.6 months to screen 720 service member s and recruit 123 participants into this study.

PAGE 52

52 If by the end of the first month of data collection, 34 participants had not completed the survey, the PI was ready to consider recruiti ng the participants in person given service member s may respond more favorably to another service member participate. The private venue for service member s to make the decision to participate or not participate would have been maintained in order to ensure that service member s understood that participating was voluntary. The details of this plan are included in Appendix H. The PI realizes that this alternative strategy would not permit blinding of the researcher and complete anonymity. However, confidentialit y could have still be en maintained especially since no identifying information was included on any of the response forms. Data M anagement Statistical Package for the Social Sciences (SPSS)(v 16.0) was used for data management and analysis. A logbook wa s maintained to record data entry, coding, and cleaning decisions, such as, data modifications or transformations in order to facilitate data reviews (Schneider & Deenan, 2004) Data c oding A code book was developed and used to organize data and to identify the coded data (e.g. variable placement in the dataset and codes and values associated with the variables). Completed questionnaires were assigned a unique case code number located in the coding c olumn of each page which was used as the case number in the statistical software program during data entry and to fac ilitate correction of discrepancies (Schneider & Deenan, 2004) Missing data were deliberately coded during the data entry process (e.g. 9,99, or 999) as this is the preferred method of identifying missing data versus leaving the field blank (Findley & Stineman, 1989;

PAGE 53

53 Ro berts, Anthony, Madigan, & Chen, 1997; Suter, 1987) In order to minimize non sampling error, the investigator coded all data directly on the data collection instrument and the coding was verified by a research assistant who was trained by the investigat or. Data c leaning Data were cleaned by producing and analyzing frequency tables and box and whisker plots (Field, 2005; Roberts et al., 1997) A frequency table was used for all categorical variables to locate out of limit values and the original data collection questionnaire was checked to determine whether the error was a coding error or an entry error. For all variables measured at the interval level, box and whisker plots were used to identify outliers which were checked against the original data collection questionnaire to determine whe ther the outliers were coding errors, entry errors, or legitimate responses. Mis sing d ata All missing data values were checked for accuracy by returning to the original data collection i nstrument. Missing data was to be handled based on the percentage of total cases with missing data. Since the number of cases with missing data represented less than 5% of the cases, no imputations were performed. If however, the numb er of cases with missing data was larger than 5%, cases w ould have been compared on dem ographic and main outcome variables to determi ne if there were any statistically significant differences between missing and non missing data cases. If there was not a significant difference (at the .05 level of significance) between the groups, then t he sample mean for the item would have replace d the missing value. If there was a statistically significant difference between cases with and cases without missing values on the main outcome variable (post deployment adjustment),

PAGE 54

54 then regression imp utation would have been utilized an d results of the imputation would be compared with the results of the statistical analysis using only complete cases (Field, 2005) If the results of the statistical analysis with only comple te cases were not similar to the statistical analysis including impute d cases, then a statistician would have been consulted to determine if an alternative imputation method would have been more appropriate. Data e ntry The standard structure for data entr y (Portney & Watkins, 2009) was followed and each variable was entered in a separate column and each row represented only one individual participant. Data from the paper questionnaires was entered twice into two separate Excel spread sheets. The investigator entered the data into sheet 1 and a trained r esearch assistant entered the data into sheet 2. The two spreadsheets were used to electronically compare the two data sets for accuracy of the entered data using the formula =F (sheet1!A1=sheet 2!A1,1,0) and values of 0 indicated on which data points the two sheets did not match. Discrepancies were printed and corrected by returning to the original paper document. Once all discrepancies had been corrected, the data were electronically read from the Excel document and saved into SPSS. The primary verifi ed data set was used for analysis and the secondary data set was archived in case the primary data set became corrupt. Dual data entry provides 100% verification of the data (Cummings & Masten, 1994) and has been shown to be superior to other methods, such as reading aloud (Kawado et al., 2003) single entry, and visual checking (Barchard, Scott, Weintraub, & Pace, 2008)

PAGE 55

55 Data Analysis Preliminary a nalysis A preliminary analysis was conducted to check for violations of statistical assumptions. The assumption of normal distribution of resilience, post deployment social support, post deployment adjustment, combat exposure, malevolent deployment environment exposure, and additional stressful life events was assessed by analyzing a histogram against the normal curve and a Shapiro Wilks. Skewness and Kurtosis values that differed significantly from zero and a statistically significant Shapiro Wilks, each at the .05 level of significance, was evidence of a possible univariate normality violation (Field, 2005) Conti nuous variables (e.g. resilience, post deployment social support, and post deployment adjustment) that were not normally distributed w ere transformed (i.e. logarithmic base 10 transformation ). Bivariate scatter plots w ere analyzed to screen for curvilinea r relationships between the predictor variables (e.g. resilience, social support, combat exposure, malevolent deployment environment exposure, and additional stressful life events) and the outcome variable (post deployment adjustment). All non linear rela tionships w ere transformed logarithmically. Extreme scores and standardized residuals w ere evaluated in the regression model (ZRE should not exceed + 1.96 or + 2.5 for more than 5% and 1% of the cases respectively). Influential extreme scores w ere identifie d by examining the DfBetas (DfBeta >1.0 were considered influential). The IV IV bivariate correlations (Pearson r, r square >.8 indicate d a concern that multicollinearity may have occur r ed) and the variance inflation factors (VIF >10 were considered evide nce of a multicollinear relationship) w ere examined to determine if multicollinearity occurred. Multicollinear problematic variables w ere identified by obtaining the eigenvalue (eigenvalue >.5). A

PAGE 56

56 null plot analyzing the constant variance of error term ( residuals from the prediction line) across the levels of the outcome variable was planned to be used to check the assumption of homoscedasticity. However, the analysis plan (including the related assumptions) was modified due to non normally distributed d ata ( Chapter 4 for more on this issue). The assumption of linear relationships would have been further assessed by analyzing the null plot of the standardized regression predicted value against the standardized regression residuals and the partial regress ion plots of the IV DV relationships controlling for the other IV. A histogram and a Shapiro Wilks of th e standardized residuals was planned to be analyzed for normality of the error term. The assumption of ind ependence of error terms would have been che cked by analyzing for patterns of the null plot and a Durbin Watson (close to 2). Main a nalysis The main statistical analysis i ncludes sample descriptions and regression analyses, including participation rates based on the percentage of service member s wh o were invited to participate who actually completed the survey. The predictors (resilience, post deployment social support, combat exposure, malevolent deployment environment, and additional stressful life events) and outcome variable (post deployment ad justment) were examined using measures of central tendency, high and low range, and standard deviation. The demographic characteristics were examined for mode and frequency distribution. The plan was to run a linear regression model to examine how much v ariance (adjusted R square) in level of adjus tment could be accounted for by resilience, post deployment social support, combat exposure, malevolent deployment environment, and additional stressful life events. The plan also included examining the F ratio for statistical sign ificance p<.05. If the model was

PAGE 57

57 statistically significant, the standa rdized beta coefficients would have been examined (t test at the .05 level of significance p<.05) to determine significant individual variable contributions and the ir relative importance to predicting adjustment. However, assessment of the distributional status of the dependent variable revealed that it was not normally distributed even after applying a series of transformations. Therefore, the analysis was modifie d and Logistic Regression was employed ( Chapter 4 for more on this issue ) Adjusting for c ovariates A secondary analysis was performed to examine characteristics of the sample that significantly influenced the main outcomes. The covariates and the depen dent variable (pos t deployment adjustment) were entered into a correlation matrix to determine if they had a significant effec t on adjustment. Those that were signific antly related to adjustment were planned to be included in Step 1 of a regression equa ti on. Step 2 would have include d the main model predictors (resilience, social support, malevolent deployment environment, combat exposure, and additional stressful life events). However, the analysis was modified due to non normally distributed data ( Cha pter 4 for more on this issue). The results of the linear regression model would have been examined to determine how much variance (adjusted R square) in level of adjustment can be accounted for by resilience, social support, malevolent deployment environ ment, combat exposure, and additional stressful life events after controlling for signific ant covariates. The F ratio would have been examined for statistical sign ificance p<.05. If the model was statistically significant, the sta ndardized beta coefficie nts would have be en examined (t test at the .05 level of significance) to determine significant individual variable contributions and their relative importance to predicting adjustment.

PAGE 58

58 Protection of Human Subjects Assurances Institution al Review Board approval was obtained from the University of Florida and the Naval Medical Center Portsmouth (The primary approving IRB for the Southeast Region of Navy Medicine inclusive of Naval Hospital Jacksonville and its Deployment Health Center). The Naval Hospita l Jacksonville and its branch health clinics (i.e. DHC) have current DoD Navy (federal wide) assurances (DoD N40010) for engaging in human subject research. The rights and dignity of all subject s involved in this study were protected. Informed Consent A waive r of written informed consent was obtained from the University of Florida and Navy IRB s. Participants were given a complete written explanation (8 th grade Flesch Kinc aid reading ) of the research study purpose, time requirements, potential risks and b enefits, and right to withdraw at any time (Appendix C). The Participant Study Informat ion Sheet explain ed the anonymous nature of the study. Participants were given an opportunity to ask the recruitment coordinator study related questions. Participants were reminded that they could dr op out at any time and this would not affect the care they receive at the NAS JAX DHC. Completing and returning of the study questionnaires serve d as implied consent. Anonymous Participation and Anonymous Responses Severa l procedures were implemented to protect the rights and dignity of human subjects involved in this research Included were standardized training for the recruitment coordinator (Appendix F), easy access to the rec ruitment coordinator who was trained and av ailable to answer questions about study participation, a private venue

PAGE 59

59 in which partici pants were stationed for making the decision to participate and for data collection and assurance of anonymous responses. Anonymous participation was maintained by all owing the service member to make the decision to participate or not participate after the recruitment coordinator had left the d ata collection room. There was no information collected that could tie participants to their responses, thus, ensuring anonym it y. All questionnaires were placed in a sealed envelope by the participant in a locked file cabinet accessible only to the investigator. Burden and Risk The burden to human subjects was expected to be low. It was expected to take 18 to 22 minutes to comp lete the packet of study questions. Those service member s invited to participate were expected to be at minimal risk ( Appendix G) since they had completed screening for beh avioral risk assessment and had not been identified as a potential harm to themselv es or others and did not have probable PTSD Those identified as having thoughts of harming themselves or others or with probable PTSD or pro bable traumatic brain injury were not included in the study to avoid unnecessary mental discomfo rt. In addition, the study did not include any experimental manipulation. The risks and side effects related to participating in this study were minimal and felt to to day life. Althoug h the risk of emotional upset was considered to be no more than minimal and similar to answering like questions posed by family or friends, participants may have been at risk for emotional upset as a result of reading and answering questions about deployment/post deployment ex periences. P articipants were instructed that they may feel free to decline to answer any questions. Moreover, a list of mental health resources was pr ovided to all participants ( Resources section below).

PAGE 60

60 Resources The investigator, a Masters prepared nurse, was avai lable to the recruitment coordinator 24/7 during the study period. There was a plan in place to refer participants who expressed any untoward reaction to study participation to the Deployment Health Psychologist by the recruitment coordinator, located in the same hallway of the data collection site, for mental health counseling. However, none of the participants expressed any untoward reaction to study participation. A list of post depl oyment related resources was given to each participant including loca l, state, and federal contact information (Appendix D).

PAGE 61

61 Table 3 1. Study variables and measurement Variable Measurement Scale Type (Format) Number of items Participant Burden (in minutes) Demographic Characteristics Investigator Developed Survey Circle and fill in response 13 1 2 Post deployme nt Adjustment Post Deployment Readjustment Inventory (PDRI) 5 point Likert 1 5 36 5 Resilience Connor Davidson Resilience Scale (CD RISC 25) 5 point Likert 0 nearly all the 25 4 Post deploy ment Social Support Post deployment Social Support Scale 5 point Likert 1 15 2 3 Deployment Environment Deployment Environment Scale 5 point Likert 1 5 20 2 3 Combat Experiences Scale 5 point Likert 1 15 2 3 Life Events Social Readjustment Rating Scale Schedule of Recent Experiences Circle Response 43 2

PAGE 62

62 Table 3 2. Covar iates and measurement Covariate Item Response Format Level of Measurement IA Experience Did you deploy as an Individual Augmentee (IA) for your most recent deployment? Yes/No Dichotomous Gender Your Gender? Male/Female (circle) Dichotomous Marital Stat us Which one of the following best describes your current marital status? Single, never married Married Living with partner Divorced Separated Widowed/Widower Discrete categorical MOS What is your Military Occupational Specialty (MOS)? Fill in Discrete ca tegorical Number of land based deployments Number of land based deployments (including the most recent deployment) (circle) 1 2 3 4 5 6 7 Continuous/Quantitative Perceived threat while deployed moments during deployment when I thought/f elt I was in great danger of being wounded or 5 point Likert scale from 1 Continuous/Quantitative

PAGE 63

63 Table 3 3. Participant accrual estimates Sample Source Description Estimate % Monthly Estimate Partici pation Totals Redeployment assessments conducted at DHC monthly 200 Estimated number of Active Duty Navy completing 90 180 day redeployment PDHRA screening. 60% 72 Expected number who do NOT meet any exclusionary criteria (based on 17% estimates of pos t deployed service member s who have a mental health diagnosis or major physical injury) (Hoge, Auchterlonie, & Milliken, 2006; Tanielian, 2008) 83% 59 Expected voluntary participation rate. 59% 34

PAGE 64

64 Figur e 3 1. Participant inclusion/exclusion screening flowsheet

PAGE 65

65 CHAPTER 4 RESULTS Well adjusted personnel who maintain readiness to deploy and carry out the members experi ence adjustment difficulties which may se verely interfere with the general health and wellbeing of service members and deployment readiness for future missions. Anonymous surveys were administered to Navy personnel who had returned from a deployment with in 3 to 6 months in order to determine the role of resilience and social support in predicting short term post deployment adjustment. Participation Accrual Rates One hundred and forty nine service member s meeting inclusion/exclusion criteria presented to the deployment health center between August 12 th 2011 and December 23 rd 2011 and were invited to participate in this study. Of the 149 surveys that were returned, 11 were left completely blank, 4 were less than half complete, and 2 were mostly complete but were missing scores on the entire dependent variable (post deployment a djustment) measure and were not useful for final analysis. Thus, 132 service member s completed the survey for an 88.5% participation rate. Sample Representativeness To determine if the sample w as representative of the total Navy force structure, the demographic characteristics of the sample were compared to the Institute of Medicine Report (2010) that described all service member s deployed to OIF/OEF ( Table 4 1). The sample in th is st udy had a higher percentage of b lack (8%), female (7%), and officer repres entation (10%) than the total Navy force. Additionally, there were fewer enlisted service member s ( 19%) between the ages of 20 and 29 indicating

PAGE 66

66 that the enlisted service memb er s in this stud y were slightly older than the Navy force structure at the time. Demographic Characteristics Similar to the Navy force structure, the characteristics of the sample in this study were m ainly white, married males ( Table 4 2). The sample wa s highly educated, consisted mainly of enlisted personnel and most had deployed for greater than 6 months to the Middle East. Just over one half of the service members in the sample deployed as Individual Augmentees (wi th units other than their own). Th e ages of the sample ranged from 20 to 50 with a mean age of 32.56 (SD=7.03) years and the number of deployments ranged from 1 to 9 with a mean of 2.3 (SD=1.86) land based deployments. There were 35 Military Occupational Specialties represented in the sa mple. For purposes of data analysis, the Military Occupational Specialties were grouped into four categories according to similarity of supportive function; 1) Healthcare professions provide medical support to personnel, 2) Tactical and Operation professi ons directly carry out the war or contingency mission, 3) Equipment and Maintenance professions repair, maintain, and or operate machines, and 4) Personnel Support occupations focus on the personal and or administrative needs of the service member s ( Table 4 3 for each Military Occupation by support categories ) Preliminary Analysis Missing Values There were no missing values on any of the main variables. Of the covariates, there were three missing cases for Military Occupational Specialty representing 2.3 % of the vali d cases, two missing cases for number of d eployments representing 1.6% of the

PAGE 67

67 valid cases, and one mis sing case for gender, Individual Augmentee status, marital status, and perceived threat while d eployed representing 0.8% of the valid cases f or each variable. A total of 5 cases had missing values representing 3.8% of the sample. Data Cleaning There were no out of limit values identified during examination of box and whisker plots for the categorical variables. The outliers that were identifi ed from box and whisker plots for the interval level variables were checked against the original data collection questionnaires and determined to be legitimate responses. Variable Descriptives See Table 4 4 for the mean, standard deviation, median, minim um, and maximum scores for the continuously measured variables. See Table 4 2 for the number (n) and percentage representation for the categorical variables. Linear regression assumes that the dependent variable is normally distributed A ssessment of the distributional sta tus of the dependent variable, post deployment a djustment, revealed that it was not normally distributed (Skewness= 1.358, Kurtosis= 1.189, and a Shapiro Wilks = .825, p = .000). The distribution remained non normally distributed after p rogressively removing up to 6 outliers. A series of data transformations including Logarithmic base 10, Inverse, Square root, Inverse Square root, and Logarithmic base 10 after anchoring the lowest score at 0 were unsuccessful in bringing the variable int o normal distribution as evidenced by Skewness and Kurtosis values greater than 1 and significant Shapiro Wilks tests. Thus, logistic regression, which assumes a dichotomous dependent variable, was used to analyze the data.

PAGE 68

68 First, normal Q Q plots wer e examine d to determine a cut point for p ost deployment adjustment. Post deployment a djustment was dichotomized int o low post deployment adjustment and high post deployment a djustment at the point in the middle of the S curve where the observed value dipp ed below the expected normal value lin e on the Normal Q Q Plot. Low post deployment a djustment was defined as scores ranging from 36 to 137, (n=23 18%) and high post deployment a djustment was defined as scores ranging from 138 to 180, (n=107 82%). To de termine the adequacy of the dichotomization, residuals were reviewed. Points (i.e. cases) to which the model fit poorly were identified by normalized residuals, standardized residuals, and deviance values > + n 1) and leverage values (values greater than twice the mean leverage for all cases) were examined to determine if any of the cases with residuals > + 1.96 were extremely influential and candidates for removal (Field, 2005). Examinatio n of the residuals r evealed 7 cases that the model fit poorly across all indices and 6 of these cases were influential. There were no inputting errors when the influential extreme cases were checked against the original data collection instrument. Removal of these cases resu lted in little improvement i n adequacy of fit of the model. Therefore, a median split tech nique was used to dichotomize post deployment adjustment into low post deployment a djustment (scores rangi ng from 36 to 168) (n= 64 49.2% ) and high post deployment a djustment (scores ranging from 169 to 180) (n=66 50.8% ). To determine the adequacy of this dichotomization, residuals were again reviewed. Examination of the residuals revealed only 3 cases that the model fit poorly across all indices and none of thes e cases were influential (e.g. none

PAGE 69

69 distances were greater than 1 and none of the cases with residuals greater than + 1.96 had leverage values greater than twice the mean). Therefore, the median split was used in the logistic regression. Marita l status was dichotomized into married or living with partner versus single (never married), divorced, or s eparated. Three dummy variabl es were created for military o cc upation. The three dummy variables were 1 ) Military Occupation dummy grouping 1 (Healt hcare support versus Equipment and Maintenance support, Personnel support non healthcare, and Tactical and operations support), 2) Military Occupation dummy grouping 2 (Tactical and operations support versus Healthcare support, Personnel support non he althcare, and Equipment and maintenance support), and 3) Military Occupation dummy grouping 3 (Personnel Support non healthcare versus Healthcare support, Tactical and operations support, and Equipment and maintenance support) ( Table 4 5). Chi square t ests and Point biserial correlations were used to determine the utility of covariates. Chi squar e tests were performed between post deployment a djustment and the dichotomous covariates (Individual Augmentee status, gender, marital status, military occupat ion grouping 1, military occupation grouping 2, and military o ccupation grouping 3) to determine if there was a relationship. Point biserial correlations were performed between post deployment a djustment and the quantitative covariates (number of deployme nts and perceived threat while d eployed) to determine if there was a relationship. Two of the covariates had significant relationships with p ost deployme nt a d d eployed, p oint biserial cor relation = .287, p < .01) ( Table 4 5). T herefore, Individual

PAGE 70

70 Augmentee status and perceived threat while d eployed were entered as covariates in the logistic regression model. Collinearity Before logistic regression, the independent vari ables (which were all continuous), sig nificant continuous covariate (perceived threat while d eployed), and significant dichotomous covariate (Individual Augmentee status) were entered into a linear regression analysis to examine multicollinearity statistic s ( Field, 2005). All of the bivariate correlations between the independent variables were less than 0.8 All of the collinearity statistics tolerance values were greater than 0.1 and all of the Variance Inflation Factors (VIF) were less tha n 10. These indices did not meet the criteria for multi collinearity (Field, 2005; Meyers, Gamst, & Guarino, 2006) Therefore, no variables were removed from the model. Main Analysis To determine if characteristics of the transition, characteristics of the environment, and characteristics of the individual predict a djustment, t he 5 main predictor variables (resilience, combat e xposure malevolent deployment environment, stressful life e vents and post deployment social s upport) were logistically regressed on post deployment a djustment. The set of predictors discri mi nated between those who had high post deployme nt adjustment and those who had low post deployment a djustment. The model was a statistically significant improvement over the constant only model, [ N=130) = 48.506, p < .001 ] The Hosmer and Lemeshow Test was non significant [ (8) =8.766, p= .362 ] indicating that the predicted probabilities match ed the observed probabilities. The Nagelkerke pseudo R indicated that the model accounted for 41.5% of the total variance in post deployment a djustment. Prediction success for the cases

PAGE 71

71 used in the development of the model was relatively high, with an overall prediction success rate of 75.4% and correct prediction rates of 77.3% for service member s with high post deployment a djustment and 73.4% for servic e member s with low post deployment a djustment. Resilience and post deployment social s upport were statistically significant predict ors of post deployment a djustment with odds ratios of 1.05 to 1.07, respectively (Table 4 6) As resilience scores increa se d the odds of post deployment a djustment occurring increased with odds of 1.05 for an incr ease of 1 unit to 13.76 for a 57 unit increase in resilience ( Table 4 7). As post deployment social support scores increased, the odds of post deployment adjustme nt occurring increased with odds of 1.07 for an increase of 1 unit to 13.64 for a 39 unit increase in post deployment social support (Table 4 7). It is also worth noting that malevolent deployment e nvironment approached significance (Wald= 3.669, p = .055 ) and may be a relevant predictor of post deployment a djustment (i.e. reach significance) in a larger sample. Adjusting for Covariates In order to determine if resilience and post deployment social s upport predict adjustment in post deployed Navy personn el when controlling for signific ant covariates, I ndividual Augmentee status and perceived threat while d eployed were added to the model. This model was a statistically significant improvement over the constant only model, [ ] The Hosmer and Lemeshow Test was non significant [ ] indicating that the predicted probabilities match ed the observed probabilities. The Nagelkerke pseudo R indicated that the model accounted for 44.7% of the total variance in post deployment a djustment. This suggests that the set of predictors continues to discr iminate between those who had

PAGE 72

72 high post deployme nt adjustment and those who had low post deployment a djustment. Prediction success for the cases used in the development of the model was relatively high, with an overall prediction success rate of 75.4% and correct prediction rates of 77.3% for service member s with high post deployment a djustment and 73.4% for service member s with low post deployment adjustment. Resilience and post deployment social s upport remain ed statistic ally significant predictors of post deployment a djustment with small increases in the odds ratios over the model without covariates ( Table 4 8 ) Therefore, even when c ontrolling for, I ndividual Augmentee status and p e rceived threat while deployed, as resilience and post deployment social s uppo rt increase d the odds of post deployment a djustment increased Although this model, which adjusts for the covariates, was a stat istically significant improvement over the constant only model, none of the covariates were significant and their contribution did not improve upon the 5 predictor model.

PAGE 73

73 Table 4 1. Study sample representa tiveness compared to total N avy force structure Ch aracteristic Navy* Sample Gender Male 89% 82 % Female 11% 18% Race/Ethnicity White 66% 52 % Black 16% 25 % Hispanic 10% 12 % Asian 4% 4 % Other 4% 4 % Military Status Enlisted 88% 78% Age 20 29 65% 46% Officer 12% 22% Age 25 39 51 % 54 % Marital Status Married 55% 56 % Single 45% 44% *Percentages are from Institute of Medicine Report (2010)

PAGE 74

74 Table 4 2. Demographic characteristics Characteristic n (%) Characteristic n (%) Gender Individual Augmentee Male 106 (82.2 %) Yes 69 (53.5%) Female 22 (17.1%) No 59 (45.7%) Marital Status Level of Education Single, never married 28 (21.7%) High school Graduate 25 (19.4%) Married 72 (55.8%) Technical school 1 (0.8%) Living with Partner 5 (3.9%) Some colle ge (no degree) 41 (31.8%) Divorced 19 (14.7%) Associates Degree 22 (17.1%) Separated 4 (3.1%) Bachelors degree 20 (15.5%) Widowed/Widower 0 (0. 0 %) Graduate degree 19 (14.7%) Race/Ethnicity Years of Education Asian 5 (3.9%) 12 years 34 (26.4%) Black 32 (24.8%) 13 15 years 52 (40.4%) Hispanic 15 (11.6%) 16 or more years 37 (28.8%) Native American 2 (1.6%) White 67 (51.9%) Deployment Length Other 5 (3.9%) 6 months or less 46 (35.8%) Greater than 6 months 81 (63 .0 %) Mi litary Rank Enlisted 100 (78 .0 %) Military Occupation Officer 28 (22 .0 %) Healthcare 38 (29.5%) Tactical and Operations 19 (14.7%) Deployment Location Equipment/ Maintenance 52 (40.3%) Middle East 72 (55.8%) Personnel Support 17 (13.2%) Cuba 21 (16.3%) Central/ South America 18 (14 .0 %) Africa 7 (5.4%) Other 8 (6.2%)

PAGE 75

7 5 Table 4 3. Military occupation support categories Support Category Military Occupation n (%) Health Care Support Nurse 6 (4.7%) Corpsman 25 (19 .4%) Physician Assistant 1 (0.8%) Preventative Medicine 1 (0.8%) Health Care Administrator 2 (1.6%) Physician 3 (2.3%) Total 38 (29.6%) Tactical and Operations Support Logistics 2 (1.6%) Air Crewman 4 (3.1%) Intelligence 3 (2.3%) Civil Engineer 1 (0.8%) Pilot 3 (2.3%) Flight Engineer 2 (1.6%) Flight Officer 1 (0.8%) Operations Specialist 2 (1.6%) Communications 1 (0.8%) Total 19 (14.9%) Equipment/ Maintenance Support Aviation Mechanic 8 (6.2%) Aviation Electr ician 6 (4.7%) Electronics Technician 12 (9.3%) Equipment Operator 2 (1.6%) Aviation Ordnance 2 (1.6%) Weapons 2 (1.6%) Aviation Technician 1 (0.8%) Maintenance Chief 1 (0.8%) Maintenance Officer 1 (0.8%) Supply 5 (3.9%) Information Systems Technician 3 (2.3%) Police 6 (4.7%) Boatswain's Mate 3 (2.3%) Total 52 (40.6%) Personnel Support (non healthcare) Religious Programs Specialist 1 (0.8%) Culinary Specialist 3 (2.3%) Yeoman 2 (1.6%) Officer Unspecified 4 (3.1 %) Administration (non healthcare) 5 ( 3.9%) Chaplain 1 (0.8%) Photo Journalist 1 (0.8%) Total 17 (13.3%)

PAGE 76

76 Table 4 4. Descriptives of continuous variables Variable M (SD) Median Min. Max. Post deployment Adjustment 158.00 (24.75) 168.50 72 .00 180.00 Resilience 79.57 (13.13) 81.00 43.00 100.00 Combat Exposure 17.83 (6.03) 15.00 15.00 52.00 Post deployment Social Support 60.16 (9.99) 60.50 36.00 75.00 Stressful Life Events 183.11 (113.73) 157.00 12.00 635.00 Malevolent Deployment Environ ment 46.17 (12.97) 46.00 20.00 79.00 Number of Deployments 2.30 (1.86) 2.00 1.00 9.00 Perceived Threat While Deployed 2.22 (1.45) 1.00 1.00 5.00 Table 4 5. C ovariate and p ost deployment a square and Point biserial correlations IA Gender Marital Status MO1 MO2 MO3 NOD PTHRT Post deployment Adjustment Chi square 4.82* .073 2.831 1.649 .275 .223 Point biserial correlation .012 .287** p < .05, **p < .01 IA = Individual Augmentee status; MO1 = Military Occupa tion dummy grouping 1 (Healthcare support versus Equipment and Maintenance support, Personnel support non healthcare, and Tactical and operations support); MO2 = Military Occupation dummy grouping 2 (Tactical and operations support versus Healthcare supp ort, Personnel support non healthcare, and Equipment and maintenance support); MO3 = Military Occupation dummy grouping 3 (Personnel Support non healthcare versus Healthcare support, Tactical and operations support, and Equipment and maintenance suppor t); NOD = Number of deployments; PTHRT = Perceived Threat While Deployed.

PAGE 77

77 Table 4 6. Logistic regression 5 predictor model of post deployment adjustment (N=130)* 95% C.I. for OR Variable SE Wald OR Lower Upper Resilience .046 .022 4.440 .035 1.047 1.003 1.093 Post deployment Social Support .067 .029 5.440 .020 1.07 0 1.011 1.132 Malevolent Deployment Environment .039 .020 3.669 .055 0 .962 0.925 1.001 Stressful Life Events .004 .002 2.868 .090 0 .996 0.992 1.001 Combat Exposure .030 .045 0 .440 .507 0 .970 0.888 1.060 SE= standard error 2loglikelihood = 131.682, Cox and Snell R = .311, Nagelkerke R = .415. Table 4 7. Odds ratios for resilience and post deployment social support scores increases and the corresponding odds of post deployment adjustment Resilience Post deployment Social Support Score Increase OR Score Increase OR 1 1.0 5 1 1.07 10 1.58 10 1.95 20 2.50 20 3.82 30 3.97 30 7.46 40 6.30 39 13.64 50 9.97 57 13.76 Score Increase = Points increase in score on Resilie nce or Post deployment Social Support scales. OR = Odds Ratio = e raised to the power of the product of the score difference x the coefficient (.046 for Resilience and .067 for Post deployment Social Support) = the odds of Post deployment Adjustment for th e range of scores represented in the sample.

PAGE 78

78 Table 4 8. Logistic regression 7 predictor model of post deployment adjustment (N=130)* 95% C.I. for OR Variable SE Wald OR Lower Upper Resilience .050 .023 4.7 00 .030 1.051 1.005 1.100 Post depl oyment Social Support .066 .029 5.031 .025 1.068 1.008 1.131 Malevolent Deployment Environment .035 .021 2.953 .086 0 .965 0 .927 1.005 Stressful Life Events .004 .002 2.734 .098 0 .996 0 .992 1.001 Combat Exposure .005 .054 0 .007 .932 1.005 0 .903 1.118 Individual Augmentee Status .746 .460 2.637 .104 2.109 0 .857 5.194 Perceived Threat While Deployed .203 .195 1.089 .297 0 .816 0 .557 1.195 SE = standard error 2loglikelihood = 127.036, Cox and Snell R = .336, Nagelkerke R = .447.

PAGE 79

79 CHAPTER 5 DISCUSSION Post deployment Adjustment For more than a decade, the U.S. Navy has supported an unprecedented high number of war and pea cekeeping missions fighting the war on terrorism throughout the world (Institute of Medicine, 2010). Thus, well adjusted personnel who maintain readiness to deploy and carry out these missions (i.e. the physical and mental wellness to support occupational compe tence) are paramount to national security. However, as many as 85% ( Shea et al., 2010) of service member s who return home for reint egration following a deployment experience adjustment difficulties in one or more personal or professional areas in the short term and 45% of those service member s with short term adjustment difficulties have persistent adjustment problems in the long term (i.e. greater than 42 months) (Sayer et al., 2010). This is a significant problem, since post deployment adjustment di fficulties can severely interfere with and hamper the general health and wellbeing of service member s, thus, interfering with deployment readiness for future missions (Bryant, 2003; Sayer et al., 2010; Sayers et al., 2009; Thompson et al., 2004) Although little has been reported on short term adjustment (Blais et al., 2009; Bowling & Shermian, 2008; Katz et al., 2010; MacDermid Wadsworth, 2010) resilience (King et al., 1999; King et al., 2006; Pietrzak et al., 2009; Pietrzak et al., 2010), social support (Engdahl et al., 1997; Kaspersen et al., 1999; King et al., 1999; King et al., 2006; Pietrzak et al., 2009), and characteristics of the transition (e.g. combat, ma levolent deployment environments, and/or additional stressful life events) (Keane et al., 2006; King et al., 2006) have been identified as factors that influence long term

PAGE 80

80 adjustment. However, this research has only been carried out on service member s two or more years after returning from deployment (Kessler et al., 1995; King et a l., 2006; Pietrzak et al., 2009 ) and included service member s with post traumatic stress di sorder (PTSD) or probable PTSD. Given the ongoing uncertainty of world affairs and th e necessary readiness for rapid multiple deployments, short term adjustment is centra l to and national security Therefore using (1981) Model for Analyzing Human Adaptation (Adjustment) to Transition th e primary purpose of this study was to determine if the factors identified as important for long term adjustment (e.g. resilience, social support, combat exposure, malevolent deployment environment exposure, and additional stres sful life events) predict ed short term adjustmen t (12 months or less) among service member s without PTSD or probable PTSD, after deployment. The secondary purpose of this study was to examine whether resilience, social support, combat exposure, malevolent deployment environments and additional stress ful life events predicted short term adjustment among service member s after deployment when controlling for military occupational specialty (MOS), gender, marital status, nu mber of land based deployments, and perceived threat while deployed. Role of Resilience and Post deployment Social Support in Adjustment The results of this study support the hypothesis that recently redeployed service member s with high resilience and high soci al support have greater post deployment adjustment. Service member s with high resilience were those who were able to adjust to adversity and life circumstances by possessing the abilities to 1) view change/stress as a challenge/opportunity and remain committed (perseverant), 2) to engage the

PAGE 81

81 support of others and pursue personal and collective goals, 3) to maintain confidence in their effectiveness and to acknowledge the strengthening effects of stress and past successes, 4) to maintain a sense of hu mor and action oriented problem solving approach, and 5) to remain patient, tolerant of n egative affect, and optimistic. Service member s with high post deployment social support endorsed the perception that family, friends, coworkers, leaders, and the com munity provided adequate emotional sustenance and instrumental assistance to the service member after returning home from deployment. and empirical evidence that characteristics of the individual expe riencing the transition (i.e. the possession of individual qualities that confer resilience) and that characteristics of the transition environment (i.e. post deployment social support) positively influence adjustment to transition. Results from this st udy showed that s ervice members who endorsed high post deployment adjustment appeared to meanin gfully integrate their transitional experiences into their personal and social lives as evidenced by their limited career, health, intimate relationship, social relationship, and stress reaction difficulties and few concerns about their deployment. These findings are similar to the findings of others who reported on short term adjustment in non military repatriated Sojourners (Herman & Tetrick, 2009; Sussman, 2001; Sussman, 2002; Szkudlarek, 2010) and veterans after long term post deployment adjustment (Engdahl et al.,1997; Kasperson et al., 2003; King et al., 1999; King et al., 2006; Pietrzak et al., 2009; Pietrzak et al., 2010). Service member s in this study (all of which screened negative for PTSD and probable PTSD),

PAGE 82

82 who endorsed higher adjustment in the short term, possessed high er levels of qualities that confer resilience and high er levels of post deployment soci al support. Characteristics of the Transition and Adjustment T he results of this study confirm that characteristics of the transition that are related to high levels of stressful exposure (e.g. combat exposure, malevolent deployment environment, and additi onal stressful life events) negatively influence adjustment to transition (Schlossberg, 1981) All three characteristics of the transition that are believed to represent high er levels of stressful exposure negatively influenced post deployment adjustment. However, none of the characteristics of the transition measured in this study displayed a statistically significant negative influence on post deployment adjustment. The refore, the results of this study did not support the hypothesis that service membe r s with low exposure to combat, malevolent deployment environments, and additional stressful l ife events have greater post deployment adjustment. Malevolent deployment environments (e.g. lack of desirable food, uncomfortable climate, cultural difficulties inadequate equipment, and long workdays), combat exposures (e.g. firing a weapon, being fired on, witnessing injury and death, and going on special missions that involve these experiences), and additional stressful life events (e.g. death of a spouse, di vorce, birth of a child) were not significantly related to post deployment adjustment. However, malevolent deployment environment did approach statistical significance (p = .055) and may have reached s ignificance in a larger sample. There are several pos sibilities that may help explain why characteristics of the transition were not significantly related to short term post deployment adjustment in the present study

PAGE 83

83 For example there may be additional salient factors that influence transition to post dep loyment adjustment that are not currently known and, thus, were not measured. Two characteristi cs of the transition (anticipation of homecoming and meaningfulness of work) that may represent salient factors in predicting post deployment adjustment were no t assessed in the present study. Adler et al. (2011) postulate that service member s who anticipate an unrealistic and, therefore, unrealized deployment homecoming transition will likely experience adjustment diffic ulties. Also, s ervice member s who found meaning in their work during deployment but not after deployment may become discontented and experience adjustment difficulties Conversely service member s who did not find meaning in their work while deployed may fail to see the usefulness of their sacr ifices and experience adjustment difficulties. Therefore, unrealistic anticipations of homecoming and lack of meaningfulness of work represent characteristics of the deployment transition that may be salient factors in short term and/or long term post dep loyment adjustment. Prior studies of the effects of combat, malevolent deployment environments, and additional stressful life events have included service member s with PTSD or probable PTSD and a conceptualization of post deployment maladjustment equatin g to psychiatric diagnoses. Adler et al. (2011) noted that in order to accurately describe the psychological experiences of service member s following a deployment the concept of post deployment adjustment needs to be expanded to include adjustment issue s that are not part of a psychiatric disorder. Adjustment was high in the present study and these service members may have experienced a different transition than in previous studies. Servicemembers experiencing PTSD or probable PTSD may be

PAGE 84

84 simultaneousl y adjusting to those disorders, as well as, the post deployment reintegration (Adler et al., 2011; Shea et al., 2010; Slone & Friedman, 2008). It may be that characteristics of the deployment (i.e. combat exposure) are important predictors of PTSD (Pietrz ak et al., 2009) but less important in predicting degree of adjustment in I n the short term, service member s may be focused on respond ing to the changes that took place in the service member ort network during deployment (Brenner et al., 2008; Gambardella, 2008; Slone & Friedman, 2008) and not the combat experiences. These include reestablishing social connections, clarifying relationship roles, and reestablishing work roles perhaps even nav igating a new working environment (Adler et al., 2011; Doyle & Peterson, 2005; Gambardella, 2008;). The primary short term task of responding to these demands may distract the service member from fully considering deployment experiences (Bowling & Shermia n, 2008). As the process of post deployment transition unfolds, these demands are either dealt with positively or negatively (Blais et al., 2010), and the service member begins to shift their f ocus and take account of deployment related experiences Henc e, combat experiences may increase in their salience for effecting long term post deployment adjustment but not short term adjustment. D ifferent coping mechanisms or at least coping mechanisms that are sustainable in the short term may not be effective or sustainable in the long term (Adler et al., 2011; Figley & Nash, 2007) Service member s may supp ress dealing with these experiences in the short term which is a necessary coping mechanism during the deployment so that they can remain focused and ready for the next mission (Ruzek et al., 2011)

PAGE 85

85 Although remaining in complete control and suppression of emotional processing is often necessary in the deployment environment (Figley & Nash, 2007), this strategy is less than ideal during the post deployment phase because eventually it interferes wi th i nterpersonal relationships (Bowling & Sher mian, 2008; Ruzek et al., 2011). T he unremitting stress of maintaining suppression is thought to take an increased emotional and psychological toll that may result in serious or chronic adjustment disorders, such as PTSD evident in long term adjustment (Ruzek et al., 2011). Whether or not it is a useful coping strategy, suppression of exposures to combat, malevolent deployment environments, and additional stressful life events may work in the short term but may n ot be sustainable in the long term If suppressed factors are not remedied in the short term, adjustment difficulties emerge or continue in the long term post deployment. Other Factors and Post deployment Adjustment There were several other factors that f rom a military standpoint were likely to be an added source of stress and may have effected adjustment The other factors that were measured in this study included Individual Augmentee status, military occupation, gender, marital status, number of land ba sed deployments, and perceived threat while deployed (Blais, Thompson, & McCreary, 2009; Charavastra & Cloitre, 2008; Figley & Nash, 2007; King et al., 2006; Street, Vogt, & Dutra, 2009; Litz, Figley & Nash, 2007;National Center for PTSD, 2008; Tannelien 2 008 ;Vasterling, 2010) Gender, marital status, military occupation, and number of land based deployments were not significantly related to post deployment a djustment and were not included as covariates in analyses. Service members with higher resilience and social support have greater post deployment adjustment after controlling for Individual Augmentee status and perceived threat while deployed. Therefore, resilience and post deployment social

PAGE 86

86 support may be more important than characteristics of the tr ansition (malevolent deployment environments, combat exposure, and additional stressful life events) in predicting short term post deployment adjustment. Limitations There are several methodological limitations of this study. The convenience sample may not be representative of the total Navy force structure. The enlisted service member s were slightly older, with 19% fewer enlisted between the ages of 20 and 29 and slightly more black (+8%) and female service members (+7%) However, Hispanic, Asian, other minority, and married service member representation was similar between the sample and the total Navy force structure. The ceiling effects of post deployment adjustment required dichotomizing it in the analyses which may have resulted in a loss of inform ation and may have reduced the power to detect significant relationships. The failure to include more service members with low post deployment adjustment reduced the variation explained by the predictors. However, i t may be that the high adjustment score s found in this sample of service members none of which had psychiatric disorders are representative of the target population F uture studies may help determine if variations in predictors account for unique patterns of domain specific post deployment adjustment, such as, career challenges, social difficulties, intimate relationship problems, and health proble ms The measu rement of stressful life events used in this study was a response format that asked respondents to circle the events that they have experienced in the last 12 months. I t was not possible to determine if the non circled events were not experienced or were missing For purposes of thi s study, it was assumed that none of the non circled items represented missing data because at least o ne item on the additional

PAGE 87

87 stressful life events instrument was identified (circled) on all cases. Moreover, there were no missing data on any of the other main variable measurement instruments. Only a select number of factors that may have affected adjust ment were administered. There may have been other salient factors that should be considered for future studies in this area (e.g. anticipation of homecoming and meaningfulness). Also, the constructs of resilience and post deployment social support are mu ltidimensional and studies that use broad measures of these constructs may increase understanding of the complex relationship between these constructs. For example, one may examine if service member s with higher resilience attract more post deployment soc ial supports which increases post deployment adjustment and service member s experiencing low post deployment adjustment may be less resilient and, therefore, unable to garner post deployment social support. Finally, the cross sectional design does not all ow for time order examination of factors predicting post deployment adjustment. Longitudinal studies are warranted to describe the transition and post deployment adjustment as it unfolds. Strengths Despite these limitations, this study is the first to e xamine the role of resilience and post deployment social support in predicting short term post deployment adjustment in Navy personnel without a diagnosis of PTSD. A strength of this study was the very high participation rate (88.5%). The high participat ion rate in this study suggests that post deployment adjustment is a topic important to redeployed service member s and that they are willing to share their experiences under the right conditions For example, in this study, face to face recruitment was employed, which was also found to be effective in other studies with military service member s (Katz et al., 2010; Newby et al., 2005).

PAGE 88

88 The anonymous response format suggested by Haas et al. (2006), McPherson et al. (2004), and Trent et al. (2007) offe red during a regular clinic visit and providing a private setting where respondents could complete the questionnaires allowed participants to work at their own pace Face to face recruitment, anonymous response formats, and private data collection venues should be employed in other studies involving service member s whenever feasible. Suggestions for Further S tudy Longitudinal studies that investigate the role of resilience and social support in predicting post deployment a djustment are needed to gain a co mplete understanding of the post deployment transition process. A possible meth od for studying the short term post deployment a djustment process is to survey service member s within 1 month post deployment, again at 3 6 months post deployment, and again at 1 year post deployment. This longitudinal approach would provide greater understanding of the post deployment transitional pro cess and establish the role of resilience and social s upport across various phases of the transition. The relationships between salient variables should be measured in all phases of the post deployment transition in order to determine the similarities and differences be tween both short and long term post deployment a djustment and would aid in determining the most appropriate types of assistance to offer service member s Inte rventions designed to increase resilience and post deployment social s upport should be developed and tested. I mportance o f This Work The Navy currently uses universal prevention measures called the Operationa l Stress Control (OSC) program to address deployment stressors (Ruzek et al., 2011) with a goal of improving adjustment across all phases of deployment, including

PAGE 89

89 redeployment. The OSC program is grounded in promoting self care (e.g. good sleep, fitness, eating habits, maintaining a sense of humor, positive attitude and social connections), and early detection of stre ss reactions in comrades and is believed to contribute to resilience building by providing informational support (Bowles & Bates, 2010; Ru zek et al., 2011). Therefore, the results of this study support the fundamental resilience and social support underpinnings of the Navy However, the OSC program was not designed to predict post deployment adjustment. One of the challenges of Navy medicine is predicting which service members are most at risk for experiencing low post deployment adjustment. Current post deployment screening measures to identify service members who need professional mental health services and thos e most at risk of experiencing adjustment difficulties include the Post deployment Health Assessment (PDHA) and the Post deployment Health Re assessment (PDHRA) which focus largely on assessing the degree of exposure to deployment stressors (e.g. exposure to combat and malevolent deployment environments) and not on resilience and post deployment social support. The results of this study are the first to show that characteristics of the transition (e.g. combat exposure and malevolent deployment environments ) may be less important than post who is most at risk for experiencing low short term post deployment adjustm ent There is also evidence that characteristics of the transition may be less important than post predicting long term post deployment adjustment. For example, Pietrzak et al. (2010) showed that post deployment social support and resilience accounted for 28% and 16%

PAGE 90

90 of the variance in post deployment adjustment, respectively whereas combat exposure only accounted for 7.8 % of the variance in long term post deployment adjustment. Therefore screening may be better served by augmen ting the current p ost deployment screening process with measures of resilience and post deployment social support. Service members identified as being most at risk for low post deployment adjustment may benefit from programs designed to assist redeployed s ervice member s adjust to family, o ccupational, and social demands. Unfortunately, these types of evidence based early interventions have not been developed because of a lack of evidence (Institute of Medicine, 2010; Ruzek et al., 2011) Unlike the transition characteristics (combat exposure, malevolent deployment environments, and additional deployment social support are modifiable. The results of this study provide additional evidence that programs designed to increase resilience and post deployment social s upport may serve as a universal prevention (i.e. Operational Stress Control program) and that providing targeted opportunities for the service member s most at risk, to increase resilience and post deployment social support will promote post deployment adjustment before adjustment difficulties emerge, worsen, or become chronic (Bryant, 2003; Sayer et al., 2010; Sayer s et al., 2009) For example, future interventions that deployment social support similar to the peer support being evaluated by the Canadian Forces in the ir Operational Stre ss Injury Social Support Program ( Figl ey & Nash 2007 ) may increase the effectiveness of the U.S. Operational Stress Control program.

PAGE 91

91 Conclusion The results of this study suggest that a ugment ing the current p ost deployment screening process with measures of resilience and post deployment soc ial support may substantially improve the ability to predict service member s most at risk for low post deployment adjustment. Although the results of this study demonstrate that efforts to build resilience and post deployment social support can contribute to higher post deployment adjustment, future studies designed to test the effectiveness of resilience and social support building programs (i.e. Operational Stress Control Program) are warranted. The resu lts of this study suggest that resilience and post deployment s ocial support may be useful assessments in determining which service member s may require more than informational support in order to adjust to post deployment transition. Finally, evidence based interventions that increase resilience and post deployment social support should be developed and tested to promote post deployment adjustment before adjustment difficulties emerge, worsen, or become chronic.

PAGE 92

92 APPENDIX A PERMISSIONS AND ENDORSEMENTS OF SCALE MODIFICATIONS

PAGE 93

93

PAGE 94

94

PAGE 95

95

PAGE 96

96

PAGE 97

97

PAGE 98

98 APPENDIX B LETTERS OF SUPPORT

PAGE 99

99

PAGE 100

100

PAGE 101

101 APPENDIX C: PARTICIPANT STUDY INTRODUCTION INFORMATION SHEET PARTICIPANT STUDY INTRODUCTION INFORMATION SHEET My name is Craig Cunningham. I am an active duty nursing student at the University of Florid a. I am doing a research study on the thoughts, actions, and social support networks for Navy persons who have deployed. I want you to share your thoughts, actions, and feelings about your experiences and your social support networks because you have de ployed and returned within the past year and I need this information to complete a research project so that I may graduate with a PhD in nursing from the University of Florida. Your choice to take part in this study is voluntary If you decide not to take part, no one will know. If you decide not to take part, simply place your blank survey in the box that will be pointed out to you and then leave. If you decide to take part in the study, please complete the survey and answer all of the questions. If an y questions bother you, you may leave them blank. You will not be asked to provide your name. There will be no way to tie you with your answers. What you share will inform me about the issues and concerns that you face every day. The purpose of this study is to gather the thoughts and feelings from Navy persons who have deployed. Taking part in this study involves reading and answering questions about your life. It should take no more than 18 22 minutes of your time. A total of 750 Navy persons w ill take part in this study. The risks to you by taking part in this study are minimal and felt to be no greater to day life. If you become upset when you answer questions about your deployment, you may also become upset wh en you answer the study questions. If you do become upset and wish to speak to someone about it, simply return to the person who gave you this packet and tell them you want a referral to talk about your upset. You may also let one of the other staff membe rs know you would like to talk to someone about a deployment issue. The research will not likely help you personally. The results may help those doing the research learn about adjusting to life after a deployment. What you share may help future Navy p ersons adjust to life after deploying. If you suffer any harm as a result of taking part in this study, treatment is available at the Jacksonville Naval Hospital and Branch Health Clinic. Any injury as a result of taking part will be assessed and treate d in keeping with the care to which you are entitled under law. If you believe you have been injured as a result of taking part in this study, you may call the legal office at 904 542 7816. If you have any questions about your rights as a person while ta king part in this study, you can contact the Clinical Investigation Department, at 757 953 5939 and/or the University of Florida Institutional Review Board at 352 273 9600. Taking part in this study is voluntary. Your choice not to take part will involv e no loss of care to which you are entitled under law. You are free to ask questions or to withdraw from the study at any time. If you choose to withdraw, you will not lose any care to which you are entitled. You have not been asked to sign a consent fo rm in order to protect your identity. By choosing to complete the questions you are indicating your consent to take part in this study.

PAGE 102

102 APPENDIX D SOURCES OF DEPLOYMENT INFORMATION Sources of Deployment Information For questions related to the research st udy contact: Craig Cunningham RN XXX XXX XXXX Military OneSource (1800 342 9647, www.militaryonesource.com ) provides access to six free private counseling sessions per problem per person with a provider in your local area for issues such as coping with deployment, reintegration, and marital and family problems. Fleet & Family Services Building 554 NAS Jacksonville, FL 32212 (904) 542 2766 Provides individual, family, and marriage counseling, classes on parenting, stress management, new parent support, personal finances and relocation services. Clinical counselors specializing in helping Individual Augmentees and their families adjust before, during, and after deploymen t. Deployment Health Center Naval Hospital Branch Health Clinic Bldg 964 NAS Jacksonville, FL 32212 904 542 3500 ext 8115 Naval Hospital Jacksonville 2080 Child St Jacksonville, FL 32214 Operational support 904 542 7458 Mental Health Information Des k 904 542 7300 MilitaryHOMEFRONT www.militaryhomefront.dod.mil Naval Hospital Portsmouth Deployment Health Center http://www.med.navy.mil/sites/nmcp/Clinics /SewellsPt/Pages/DeploymentHealthCenter .aspx Deployment Health & Family Readiness Library http://deploymenthealthlibrary.fhp.os d.mil Naval Ho spital Portsmouth Psychiatry 757 953 5269 Psychology 757 953 7641 National Military Family Association www.nmfa.org Online mental health screening tools Anonymous self assessments for depression, alcohol disorder, post traumatic stress disorder (PTSD), generalized anxiety disorder, and bipolar disorder are available online at www.MilitaryMentalHealth.org

PAGE 103

103 APPENDIX E MEASUREMENT INSTRUMENTS Demographics : Please answer the following questions about your military history and your personal background by circling or filling in the correct response. Do not write in this column 1. What is your Military occupation (fill in) 2. What is your Military rank (fill in) 3. What was the location of your most recent deployment (fill in) 4. How many months were you away from home on your most recent deployment? (fill in) 5. Did you deploy as an Individual Augmentee (IA) for your most recent deployment? (Circle nu mber) 0. NO 1. YES 6. How many land based deployments (including your most recent deployment) have you experienced (circle)? 1 2 3 4 5 6 7 7. What is your age (in years) (fill in) 8. What is your gender (circle) 0. Male 1. Female 9. What is your race/ethnicity (circle) 1. Asian 2. B lack 3. Hispanic 4. Native American 5. White 6. Other

PAGE 104

104 Demographics (Continued) : Please answer the following questions about your military history and y our personal background by circling or filling in the correct response. Do not write in this column 10. What is your level of education (circle) 1. Did not graduate high school 2. High school graduate (including GED) 3. Technical school 4. Some coll ege (no degree) 5. Associates Degree 6. Bachelors degree 7. Graduate Degree 11. How many years of education have you completed? (fill in) 12. What is your current relationship status (circle) 1. Single, never married 2. Married 3. Living with partner 4. Divorced 5. Separated 6. Widowed 13. How long (in years) have you been at your current relationship status from question 13? (fill in)

PAGE 105

105 Although permission was given for use of the CD RISC (Resilience) scale, a copy of the CD RISC (R esilience) scale was not included as part of user agreement : All rights reserved. No part of this document may be reproduced or transmitted in any form, or by any means, electronic or mechanical, including photocopying, or by any information storage or retrieval system, without permission in writing from Dr. Davidson at david011@mc.duke.edu. Copyright 2001, 2003, 2007, 2009 b y Kathryn M. Connor, M.D., and Jonathan R.T. Davidson, M.D.

PAGE 106

106 Post Deployment Social Support : The next set of statements refers to so cial support after deployment. Please decide how much you agree or disagree with each statement and circle the number that best fits your choice. Do not write in this column After Deployment: Strongly disagree Somewhat disagree Neither agree nor disagree Somewhat agree Strongly agree 1. The reception I received when I returned from my deployment made me feel appreciated fo r my efforts. 1 2 3 4 5 2. The American people made me feel at home when I returned. 1 2 3 4 5 3. When I returned, people made me feel proud to have served my country in the Armed Forces. 1 2 3 4 5 4. I am carefully listened to and understood by fami ly members or friends. 1 2 3 4 5 5. Among my friends or relatives, there is someone who makes me feel better when I am feeling down. 1 2 3 4 5 discuss with family or friends. 1 2 3 4 5 7. Among my friends or relatives, there is someone I go to when I need good advice. 1 2 3 4 5 understand what I have been through while in the Armed Forces. 1 2 3 4 5 9. There are people to whom I can talk about my deployment experiences. 1 2 3 4 5

PAGE 107

107 P ost Deployment Social Support (Continued ) : The next set of statements refers to so cial support after deployment. Please decide how much you agree or disagree with each statement and circle the number that best fits your choice. Do not write in this column After Deployment: Strongly disagree Somewhat disagree Neither agree nor disagree Somewhat agree Strongly agree 10. People in my community respect the fact that I am a service member 1 2 3 4 5 11. My supervisor understands when I need time off to take care of personal matters. 1 2 3 4 5 12. My friends or relatives would lend me money if I needed it. 1 2 3 4 5 13. My friends or relatives would help me move my belongings if I needed to. 1 2 3 4 5 14. When I am unable to attend to daily chores, ther e is someone who will help me with these tasks. 1 2 3 4 5 15. When I am ill, friends or family members will help out until I am well. 1 2 3 4 5

PAGE 108

108 Post Deployment Readjustment Inventory Please rate how true each of the following is since your return from deployment by writing the number that corresponds to the scale above Do not write in this column Not at all Slightly Somewhat Considerably Extremely 1 2 3 4 5 1. Feeling pressure to work 2. Having chronic pain 4. Feeling tense, jittery, or anxious 5. Difficulty returning to my role in my family 6. Feeling unmotivated to work 7. Not fitting in socially 8. Having health problems 9. Worried about others who are still de ployed 10. Avoiding social situations or crowded places 11. My body not functioning like it used to 12. Mourning the death of fellow service member s 13. Wanting to work but not being able to 14. Feeling like I am deteriorating 15. Not wan ting to be touched or hugged 16. Missing structure and focus of being deployed 17. Having demands from my partner or family 18. Having difficulty concentrating 20. Feeling tired and worn out 21. Bei ng easily irritated with others 22. Something was kept secret while I was away 23. Having difficulty managing my job 24. Having frequent thoughts about deployment 26. Feeling useless since retu rning from deployment 27. Feeling alienated or alone

PAGE 109

109 Post Deployment Readjustment Inventory (continued) Please rate how true each of the following is since your return from deployment by writing the number that corresponds to the scale above Do not w rite in this column Not at all Slightly Somewhat Considerably Extremely 1 2 3 4 5 28. My life is on hold (could be redeployed) 29. Having difficulty completing tasks 30. Having lots of medical appointments 31. My partner/family does not unde rstand me 32. Having nightmares or difficulty sleeping 33. Not wanting to talk about my experiences 34. Not knowing what to do next 35. Wanting to avoid intimate time with others 36. Everything seems trivial since deployment

PAGE 110

110 Deployment E nvironment : The next set of statements is about the conditions of day to day life during your deployment. Please read each statement and decide what amount of time you were exposed to each condition over the course of the entire time you were deployed. C ircle the number below the appropriate response. Do not write in this column While deployed: Almost none of the time A few times Some of the time Most of the time Almost all of the time 1. The climate was extremely uncomfortable 1 2 3 4 5 2. I had to deal with annoying animals, insects, or plants during my deployment. 1 2 3 4 5 3. I had access to clean clothing when I needed it. 1 2 3 4 5 4. I could get a cold drink (for example, water, juice, etc.) when I wanted one. 1 2 3 4 5 5. The food I had to eat was of very poor quality (for example, bad or old MREs). 1 2 3 4 5 6. The conditions I lived in were extremely unsanitary. 1 2 3 4 5 7. I had access to bathrooms or showers when I needed them. 1 2 3 4 5 8. I got as much sleep as I needed. 1 2 3 4 5 9. The living space was too crowded. 1 2 3 4 5 10.I was able to get enough privacy 1 2 3 4 5 11 The workdays were too long. 1 2 3 4 5 12. I got the R&R (rest and relaxation) that I needed. 1 2 3 4 5 13. I got my mail in a timely manner. 1 2 3 4 5 14. I was exposed to awful smells. 1 2 3 4 5 15. I was subjected to loud noises. 1 2 3 4 5 16. I had to hassle with putting on and taking off NBC equipment. 1 2 3 4 5 17. I had the equipment or supplies to do what I needed to do. 1 2 3 4 5 18. My daily activities were restricted because of local religious or ethnic customs. 1 2 3 4 5 19. I felt comfortable living in the culture or cultures where I was deployed. 1 2 3 4 5 20. Pressure to conform to the local culture made it difficult for me to do my job. 1 2 3 4 5

PAGE 111

111 Combat Experiences (modified) : The statements below are about your combat experiences during deployment. Please read each statement and decide what amount of time you were exposed to each condition during your deployment. Circle the number below the appropriate response. Do not write in this column While deployed: Never A few times over entire deployment A few times each month A few times each week Daily or almost daily 1. I went on combat patrols or missions. 1 2 3 4 5 2. I or members of my unit encountered land or water mines and/or booby traps. 1 2 3 4 5 3. I or members of my unit received hostile incoming fire from small arms, artillery, rockets, mortars, or bombs. 1 2 3 4 5 4. I or members of my unit receiv ed artillery, rockets, mortars, or bombs. 1 2 3 4 5 5. I was in a vehicle (for example, a truck, tank, APC, helicopter, plane, or boat) that was under fire. 1 2 3 4 5 6. I or members of my unit were attacked b y terrorists or civilians. 1 2 3 4 5 7. I was part of a land or naval artillery unit that fired on the enemy. 1 2 3 4 5 8. I was part of an assault on entrenched or fortified positions. 1 2 3 4 5 9. I took part in an invasion that involved naval a nd/or land forces. 1 2 3 4 5 10. My unit engaged in battle in which it suffered casualties. 1 2 3 4 5 11. I personally witnessed someone from my unit or an ally unit being seriously wounded or killed. 1 2 3 4 5 12. I personally witnessed soldiers fro m enemy troops being seriously wounded or killed. 1 2 3 4 5 13. I was wounded or injured in combat. 1 2 3 4 5 14. I fired my weapon at the enemy. 1 2 3 4 5 15. I killed or think I killed someone in combat. 1 2 3 4 5

PAGE 112

112 Life Events : Circle each event that has taken place in your life in the last 12 months Do not write in these columns 1. Death of a spouse 100 2. Divorce 73 3. Marital Separation 65 4. Jail term 63 5. Death of a close family member 63 6. Personal injury or illness 53 7. Marriage 50 8. Fired at work 47 9. Marital reconciliation 45 10. Retirement 45 11. Change in health of family member 44 12. Pregnancy 40 13. Sex difficulties 39 14. Gain of a new family member 39 15. Business readjustments 39 16. Change in financial state 38 17. Death of a close friend 37 18. Change to different line of work 36 19. Change in number of arguments with spouse 35 20. Mortgage over $50,000 31 21. Foreclosure of mortgage 30 22. Change in responsibiliti es at work 29 23. Son or daughter leaving home 29 24. Trouble with in laws 29 25. Outstanding Personal achievement 28 26. Spouse begins or stops work 26 27. Begin or end school 26 28. Change in living conditions 25 29. Revision of personal ha bits 24 30. Trouble with boss 23

PAGE 113

113 Life Events (continued) : Circle each event that has taken place in your life in the last 12 months Do not write in these columns 31. Change in work hours or conditions 20 32. Change in residence 20 33. Change in s chool 20 34. Change in recreation 19 35. Change in religious activities 19 36. Change in social activities 18 37. Loan less than $50,000 17 38. Change in sleeping habits 16 39. Change in number of family get togethers 15 40. Change in eating habits 15 41. Vacation 13 42. Holidays 12 43. Minor violation of laws 11 Perceived threat while deployed : Please decide how much you agree or disagree with the following statement and circle the number that best fits your choice. Do not write i n this column Strongly disagree Somewhat disagree Neither agree nor disagree Somewhat agree Strongly agree 1. There were moments during deployment when I thought/felt I was in great danger of being wounded or killed. 1 2 3 4 5

PAGE 114

114 You have completed the survey! Please remove the Participant Study Information Sheet and the Sources of Deployment Information to take with you for future reference. Once you have removed the Participant Study Information Sheet and the Sources of Deployment Information, place seal, and place it through the slot in the file cabinet. THANK YOU FOR PARTICIPATING IN THIS RESEARCH STUDY AND FOR YOUR SERVICE TO OUR COUNTRY!

PAGE 115

115 APPENDIX F RECRUITMENT COORDINATOR TRAINING MANUAL Recruitment Coordinator Training Manual Purpose The purpose of this training was to ensure that the incumbent for the position of implement study participant screening, recruiting, and survey administration protocol so that the integrity of the data, and the rights and dignity of all individuals who were screened, recruited, or participated in this research were protected. Prerequisite The Department of the Navy and the University of Florida require human research ethics training of all investigators and key research personnel prior to conducting research. This requirement applies to all research from simple, minimal risk chart reviews and psychosocial surveys to risky experimental drug trials and surgical procedures. At a minimum, the trainee had completed the following set of Collaborative Institutional Training Initiative (CITI) modules required by the Navy and the University of Florida for Key Research Personnel with a social behavioral focus: Investigators and Key Research Personnel Social/Behaviorial (SBR) Focus 1. Belmont Report and CITI Course Introduction 2. Department of The Navy Introduction 3. History and Ethical Principle s SBR 4. Defining Research with Human Subjects SBR 5. The Regulations and The Social and Behavioral Sciences SBR 6. Assessing Risk in Social and Behavioral Sciences SBR 7. Informed Consent SBR 8. Privacy and Confidentiality SBR 9. Records Based Research 10. Research With Protected Populations Vulnerable Subjects: An Overview 11. Internet Research SBR 12. Group Harms: Research With Culturally or Medically Vulnerable Groups 13. Hot Topics 14. Conflicts of Interest in Research Involving Human Subjects 15. Department of the Navy HRPP Module 16. Department of the Navy Information and References Additionally, the University of Florida requires the following training for key study personnel: 1. Read the Belmont Report (covered in C ITI training) 2. Read the Code of Federal Regulations 3. Read the UF IRB Policies and Procedures 4. Read the Researcher Responsibilities 5. Complete the HIPAA for Researchers training modules Methods

PAGE 116

116 Required reading, role playing, rehearsal, and feedback were used t o prepare the trainee to implement screening, recruitment, and survey administration procedures. These strategies were shown to increase the likelihood of adherence to study protocols (Hubal & Day, 2006; Kratoc hwill, Elliott, & Busse, 1995; Sterling Turner, Watson, Wildmon, Watkins, & Little, 2001; Sterling Turner, Watson, & Moore, 2002) Materials 1. Written Procedures Section 2. Written Quiz on Study Procedures 3. Written Quiz on Study Procedures Answer Key 4. Part icipant Inclusion/Exclusion Screening Flow Sheet 5. Practice Forms (9 DD FORM 2900 and PCL M forms with fictitious data that represent individuals that should and should not be included in the study) 6. Practice Forms Answer Key 7. Script f or I ntrod ucing the S tud y 8. Potential Participant Questions 9. Participant Study Introduction Information Sheet Procedures The following activities were engaged in by the trainee and the PI until both parties agreed that mastery had been achieved. 1. procedures to the PI. 2. the trainee was expected to master the material, the trainee could have taken the quiz as many times as necessary until 100% proficiency was achieved. 3. Participant Inclusion/Exclusion S creening M completed with fictitious data) should be included in the study. Practice continued until the trainee made accurate inclusion/exclusion decisions for all 9 fictitious individuals with 100% accuracy. 4. The trainee practiced recruitment (during role play) or I ntrod ucing the S tudy the role of a potential participan t. Role playing continued until both the PI and the trainee believed that the trainee had mastered the activity. 5. The trainee practiced answering study related questions (during role play) by verbally .g. Do I have to participate? What is the purpose of the research? and How long will it take?) The trainee use d the in Study Introduction to answer these questions. Role playing continued until both the PI and the trainee believed that the trainee had mastered the activity.

PAGE 117

117 Copy of Required Materials Written Procedures S ection Recruitment Service member s returning from deployment are required to undergo military physical and psychological screening at two time points (within 30 days and 90 180 days). The study sample will be recruited from the DHC when ser vice member s report to complete the second of these two required post deployment health screenings. This time point and venue was selected for several reasons. The first reason relates to the timing of the post deployment health reassessment screening th at coincides with the time point when readjustment concerns begin to emerge at higher rates three to six months after deployment (Milliken et al., 2007) Second, recruiting participants from the DHC provides 1 ) a centralized location to access the post deployed naval personnel assigned to the various tenant commands, 2) a location where service member s expect to discuss physical and behavioral health needs, 3) reduced risk to participants by integrating study p rocedures into routine screening procedures already being performed at the DHC, 4) medical and behavioral health resources will be in close proximity in the unlikely event a participant has untoward reaction to study participation, and 5) the service membe r s do not have competing work demands when they report to the DHC. All active duty Navy personnel completing their post deployment health reassessment will be eligible for screening and inclusion in this study. Therefore, the demographic characteristic s of the sample population are expected to include gender and minority representation that approximates the demographic characteristics of post deployed Navy personnel at NAS JAX (e.g. 89% male, 66% white, 16% b lack, 10% Hispanic, 4% Asian, and 4% other). Recruitment support Letters of support have been obtained from the Division officer of the Jacksonville Naval Hospital Branch Health Clinics, the Department Head of the DHC, the Deployment Health Psychologist and Program Manager at the DHC, and the Phys ician Assistant (PA) responsible for conducting the PDHRAs (Appendix B Letters of Support). A waiver of HIPAA authorization will be obtained from the University of Florida and the US Navy to review medical records necessary to determine those service me mber s who meet study inclusion/exclusion screening criteria. The DHC Physician Assistant responsible for conducting the PDHRA interview has agreed to be the recruitment coordinator for this study ( Appendix B letter s of support ). The recruitment coord inator will screen, recruit, and administer the study survey, thus blinding the investigator to the identity of participants and making this an anonymous survey. Maintaining anonymity has been shown to increase research study participation in adult popula tions surveyed while waiting for clinic appointments (McPherson & Schwenka, 2004) during hospital admiss ions (Haas & Pazdernik, 2006 ) among military personnel during training (Trent et al., 2007) and among military personnel during the post deployment readjustment period (Wright et al., 200 5) The recruitment coordinator has participated in conducting research at other medical treatment facilities and is familiar with the conduct of research in clinical settings. The recruitment coordinator is not a military service member thus enhancing study protocol fidelity that is maximized since relocation of this person is unlikely during the study

PAGE 118

118 period. In the unlikely event the recruitment coordinator is no longer employed at the DHC, the Deployment Health Psychologist and Program Manager (who is also not a military service member and unlikely to relocate during the study period) has agreed to support the utilization of another DHC staff membe r as a recruitment coordinator ( Appendix B). The advantages to utilizing the DHC staff as the recruitm ent coordinator include efficiency, minimizing disruption of the post deployment screening process, and the ability for participants to remain anonymous to the investigator. Screening and recruitment procedures Screening for inclusion in the study and r ecruitment will take place at the conclusion of the Navy mandated physical and psychological screening interview, which is recorded on DD FORM 2900 (PDHRA) and supplemented with the PCL M form at the DHC. Responses on DD FORM 2900 and the PCL M provide th e interviewer with the necessary information to screen participants for study inclusion/exclusion. The recruitment coordinator (PA) will view the forms but not extract data to minimize the effort of the recruitment coordinator so as not to impact on their ability to complete their regular mission of identifying the physical and mental health needs of service member s and referring them as necessary. Since the PA reviews the information on the 2900 and the PCL M as part of the PDHRA interview, the amount of additional time to screen and recruit for study inclusion is expected to average between 2 3 minutes per participant. The recruitment coordinator will use the Participant Inclusion/Exclusion Screening Flow Sheet (Figure 1) to guide decisions on which s ervice member s meet study inclusion/exclusion criteria. Recruiting service member s using this method is expected to lead to a representative sample of the target population and to recruit service member s who meet study inclusion/exclusion criteria (Butterfield et al., 2003) Informed Consent All service member s who meet inclusion criteria will be provided with the participant information sheet (Appendix C) that contains a writt en description of the study including the study purpose, procedures, duration, risks, benefits, and the right to withdraw at any time without penalty. They will also be provided a list of deployment related resources (Appendix D), and a study packet that contains the study questionnaires (Appendix E). The recruitment coordinator will be trained to respond to service member investigator will be available to the recruitment coordinator should there be a question or concern that cannot be addressed. Completing and returning the study questionnaires will serve as documentation of implied informed consent. Data Collection Once all questions and concerns are addressed, the recruitment coordinator will escort part icipants to a room that affords privacy and shown where to place the study packet when completed. Participants can decide to complete the study packet or not complete the study packet and place either the completed or the non completed forms in the locked file cabinet. The investigator will collect completed surveys from the file cabinet at the end of each data collection day. Thi s process will continue until 123 participants who meet inclusion criteria have completed the survey.

PAGE 119

119 Written Quiz on Stu dy P rocedures 1. Circle all service member s from the list below who are eligible to be screened for participation in this study: a. Navy personnel completing their Pre deployment health screening. b. Navy personnel completing their 30 day post deployme nt health screening. c. Navy personnel completing their 90 180 day post deployment health screening. 2. My role in this study is to function as the recruitment coordinator. True or False 3. One advantage to using the DHC staff member as the recruitmen t coordinator is to blind the investigator to the identity of participants making this an anonymous survey. True or False 4. When will screening for inclusion in the study and recruitment take place? 5. Which documents will be used to obtain data on wh ich to base inclusion/exclusion decisions? a. DD Form 2900 b. PCL M c. Participant Inclusion/Exclusion Screening Flow Sheet 6. Which documents will be used to guide decisions on which service member s meet study inclusion/exclusion criteria? a. DD Form 2900 b. PCL M c. Participant Inclusion/Exclusion Screening Flow Sheet 7. All service member s who meet inclusion criteria will be provided with the participant information sheet that contains a written description of the study including the study purpose, procedures, duration, risks, benefits, and the right to withdraw at any time without penalty. True or False 8. Circle all of the True statements from the list below: a. All service member s who meet inclusion criteria will be provid ed a list o f deployment related resources and a study packet that contains the study questionnaires. b. The recruitment coordinator will be trained to respond to service member questions or concerns about the study. c. Service member ut the study will be re ferred to the principle investigator (LCDR Cunningham). d. Completing and returning the study questionnaires will se rve as documentation of implied informed consent. 9. When will the recruitment coordinator escort participants to the data collection room? 10. When will service member s make their decision to participate (complete or not complete the study packet questionnaires)?

PAGE 120

120 Written Quiz on Study Procedures Answer Key 1. Circle all service member s from the list below who are eligible to be screened for participation in this study: (correct response c) a. Navy personnel completing their Pre deployment health screening. b. Navy personnel completing their 30 day post deployment health screening. c. Navy personnel completi ng their 90 180 day post deployment health screening. 2. My role in this study is to function as the recruitment coordinator. True or False 3. One advantage to using the DHC staff member as the recruitment coordinator is to blind the investigator to th e identity of participants making this an anonymous survey. True or False 4. When will screening for inclusion in the study and recruitment take place? At the conclusion of the Navy mandated physical and psychological screening interview (PDHRA). 5. W hich documents will be used to obtain data on which to base inclusion/exclusion decisions? (correct responses a and b) a. DD Form 2900 b. PCL M c. Participant Inclusion/Exclusion Screening Flow Sheet 6. Which documents will be used to guide decision s on which service member s meet study inclusion/exclusion criteria? (correct response c.) a. DD Form 2900 b. PCL M c. Participant Inclusion/Exclusion Screening Flow Sheet 7. All service member s who meet inclusion criteria will be provided with the p articipant information sheet that contains a written description of the study including the study purpose, procedures, duration, risks, benefits, and the right to withdraw at any time without penalty. True or False 8. Circle all of the True statements fr om the list below: (correct responses a,b, and d) a. All service member s who meet inclusion criteria will be provided a list of deployment related resources and a study packet tha t contains the study questionnaires. b. The recruitment coordin ato r will be trained to respond to service member questions or concerns about the study. c. Service member principle investigator (LCDR Cunningham). d. Completing and returning the study questionnaires will serve as documentation of implied informed consent. 9. When will the recruitment coordinator escort participants to the data collection room? Once all questions and concerns have been addressed 10. When will service member s make their decision to participate (complete or not complete the study packet questionnaires)? Once the recruitment coordinator has left the data collection room

PAGE 121

121 Participant Inclusion/Exclusion Screening Flow Sheet Completing PDHRA? Do NOT administer survey NO Do NOT administer survey Active Duty Na vy (DD FORM 2900, pg 1)? NO YES YES YES Total PCL M score > 50? NO At leas t 1 reexperiencing symptom on PCL M at moderate level or above? (item #s 1 5) At least 3 avoidant/numbing symptoms on PCL M at moderate level or above? (item #s 6 12) At least 2 hyperarousal symptoms on PCL M at moderate level or abov e? (item #s 13 17) NO NO NO Administer survey YES YES YES Do NOT administer survey Does service member pose a current risk for harm to self or others (DD FORM 2900, pg 4, #3a)? Do NOT administer survey YES NO

PAGE 122

122 Practice Forms (9 DD FORM 2900 and PCL M forms with fictitious data that represent individuals that should and should not be included in the study)

PAGE 123

123

PAGE 124

124

PAGE 125

125

PAGE 126

126

PAGE 127

127

PAGE 128

128

PAGE 129

129

PAGE 130

130

PAGE 131

131

PAGE 132

132

PAGE 133

133

PAGE 134

134

PAGE 135

135

PAGE 136

136

PAGE 137

137

PAGE 138

138

PAGE 139

139

PAGE 140

140

PAGE 141

141

PAGE 142

142

PAGE 143

143

PAGE 144

144

PAGE 145

145

PAGE 146

146

PAGE 147

147

PAGE 148

148

PAGE 149

149

PAGE 150

150 Practice Forms Answer Key Hi ghlighted areas are reasons for excluding participation Practice Form # DD Form 2900 PCL M S=score, R=reexperiencing symptoms, A=avoidance/numbing symptoms, H=hyperarousal symptoms Include/Exclude 1. Active Duty/ No risk for harm S = 34 INCLUDE 2. Acti ve Duty/ No risk for harm S = 51, R=5, A=7, H=5 EXCLUDE 3. DD Form 2796 (PDHA and not PDHRA) S= 40 EXCLUDE 4. Active Duty/ No risk for harm S=52, R=3, A=4, H=3 EXCLUDE 5. Active Duty/ No risk for harm S=51, R=3, A=4, H=4 EXCLUDE 6. Active Duty/ No ris k for harm S=57, R=5, A=0, H=5 INCLUDE 7. Reserve / No risk for harm S=40 EXCLUDE 8. Active Duty/ Unsure risk for harm S=34 EXCLUDE 9. Active Duty/ Risk for harm S=50 EXCLUDE

PAGE 151

151 Script for Introducing the Study We have completed the post deploymen t health reassessment. The commanding officer of the Naval Hospital has given permission to LCDR Cunningham, who is a Duty Under Instruction (DUINS) doctoral student at the College of Nursing at the University of Florida, to conduct a research study here at the Deployment Health Center. LCDR Cunningham is conducting a research study related to post deployment adjustment experiences. Study participation involves completing a written survey that is expected to take between 18 to 22 minutes of your time. H ere is a description of the study (hand Please read the Study Introduction Information Sheet. After the service member is finished reading, ask if they have any quest ions. If service member has met all inclusion/exclusion criteria contained on the DD FORM 2900 and the PCL M, the recruitment coordinator will then follow the script below: IF Service member answers YES then answer their questions. IF Service member answers NO or on ce all of their questions have been answered, then read the following: I will now show you to a private location next door where you can make your decision to participate or not participate. If you decide to participate, please complete the study questionnaires and place them through a slot into a locked file cabinet that is located in the room where you will be located. The cabinet will be clearly marked. Your decision about participating in this study is anonymous. If you decide to participate, complete the survey and deposit it in the metal file cabinet and then leave. If you decide not to participate, leave your survey blank and deposit it in the metal file cabinet and then leave.

PAGE 152

152 Potential Participant Questions Question Answer Do I have to participate in the study? No, you do not have to participate in this study. This study is completely voluntary. If you decide not to participate, your decision will not a ffect the care you receive at the DHC. What is the purpose of this study? The purpose of this study is to obtain information about the needs of Navy personnel like you have after deployment. How long will it take? It will take approximately 18 22 minut es of your time to complete the questionnaires. Once you submit your surveys your involvement in the study will be finished. What do I have to do to participate? The procedure for this study involves reading and completing a post deployment questionnaire and returning the completed questionnaire. How many people will participate? A total of 123 service member s are expected to participate. Are there any risks to me if I participate? The risks and side effects related to participating in this study are ex pected to be minimal and felt to be no greater to day life. Although the risk of emotional upset is considered to be no more than the risk of answering similar questions posed by family or friends, you may be at risk for emotional upset as a result of reading and answering questions about your deployment or post deployment experiences. You may feel free to decline to answer any questions. The only expected inconvenience will be the time needed to complete the questio nnaires.

PAGE 153

153 Potential Participant Questions (continued) Question Answer How will I benefit from participating in the study? The research is not expected to help you personally but the results may help the investigator learn about resilience, social support, and post deployment adjustment experiences. The information gained from your participation will be helpful in providing information that can be useful in aiding future service member s with post deployment adjustment. Who do I contact if I belie ve that I have been injured from participating in this or any study? If you believe you have been injured as a result of participating in this research study, you may call the legal office at 904 542 7816. Can I decide not to participate once I begin comp leting the questionnaires? Yes, you may withdraw from the study at any time. Your withdrawal will involve no loss of benefits to which you are entitled. Will my command know that I participated or how I responded? No, you have not been asked to sign this consent form in order to protect your identity. No personal identifying information will be collected, including no signature. If I participate, will my responses be documented in my record? No, no personal identifying information will be collected, i ncluding no signature. Therefore, your responses are completely anonymous.

PAGE 154

154 PARTICIPANT STUDY INTRODUCTION INFORMATION SHEET My name is Craig Cunningham. I am an active duty nursing student at the University of Florida. I am doing a research study on the thoughts, actions, and social support networks for Navy persons who have deployed. I want you to share your thoughts, actions, and feelings about your experiences and your social support networks because you have deployed and returned within the past year and I need this information to complete a research project so that I may graduate with a PhD in nursing from the University of Florida. Your choice to take part in this study is voluntary If you decide not to take part, no one will know. If yo u decide not to take part, simply place your blank survey in the box that will be pointed out to you and then leave. If you decide to take part in the study, please complete the survey and answer all of the questions. If any questions bother you, you may leave them blank. You will not be asked to provide your name. There will be no way to tie you with your answers. What you share will inform me about the issues and concerns that you face every day. The purpose of this study is to gather the thought s and feelings from Navy persons who have deployed. Taking part in this study involves reading and answering questions about your life. It should take no more than 18 22 minutes of your time. A total of 750 Navy persons will take part in this study. T he risks to you by taking part in this study are minimal and felt to be no greater to day life. If you become upset when you answer questions about your deployment, you may also become upset when you answer the study questio ns. If you do become upset and wish to speak to someone about it, simply return to the person who gave you this packet and tell them you want a referral to talk about your upset. You may also let one of the other staff members know you would like to talk to someone about a deployment issue. The research will not likely help you personally. The results may help those doing the research learn about adjusting to life after a deployment. What you share may help future Navy persons adjust to life after dep loying. If you suffer any harm as a result of taking part in this study, treatment is available at the Jacksonville Naval Hospital and Branch Health Clinic. Any injury as a result of taking part will be assessed and treated in keeping with the care to w hich you are entitled under law. If you believe you have been injured as a result of taking part in this study, you may call the legal office at 904 542 7816. If you have any questions about your rights as a person while taking part in this study, you ca n contact the Clinical Investigation Department, at 757 953 5939 and/or the University of Florida Institutional Review Board at 352 273 9600. Taking part in this study is voluntary. Your choice not to take part will involve no loss of care to which you are entitled under law. You are free to ask questions or to withdraw from the study at any time. If you choose to withdraw, you will not lose any care to which you are entitled. You have not been asked to sign a consent form in order to protect your ide ntity. By choosing to complete the questions you are indicating your consent to take part in this study.

PAGE 155

155 APPENDIX G DATA SAFETY MONITORING STUDY RISK ASSESSMENT Attachment #2 Data Safety Monitoring Study Risk Assessment Use this table to assess the ris vulnerability and to derive an estimate of the overall risk of your study. For each factor, enter the appropriate score and then sum the scores. Principal Investigator: ___ Craig Cun ningham__ _Date:________ Study title: __ The role of resilience and so cial support in predicting post d eployment adjustment in Navy personnel. ENTER SCORE I. Experimental Treatment Low Risk No experimental treatment in study 1 point 1 Moderate Risk Tre atment effects documented from studies with similar and/or different populations and/or settings. No serious adverse events expected. Specific plans to monitor AEs detailed in DSMP 2 points High Risk Experimental treatment is being regulated by the FDA (e.g. investigational drug, device, or biologic) 4 points II. Procedures, Measurements, and Data Collection Methods Low Risk Minimally invasive with low degree of emotional and/or physical discomfort. Probability of adverse events is low. Severity ( magnitude) of adverse events is low. (Procedure may be rated low if probability of AE is moderate to high as long as the severity is low, as in the case of a bruise from phlebotomy) (e.g. procedures that meet IRB criteria for expedited review) 1 point 1 Moderate Risk Moderate degree of emotional and/or physical discomfort. Probability of adverse events is low. Severity of adverse events is moderate to high. (e.g. PET scan, lumbar puncture, arterial lines) 2 points High Risk Moderate to high degree of emotional and/or physical discomfort. Probability of adverse events is moderate to high. Severity of adverse events is high. (e.g. heart muscle biopsy, insulin infusion) 4 points III. Decision making Capability Non vulnerable Adult who 1) demonstra tes decision making capacity and 2) demonstrates no perception of undue influence or coercion to participate. 1 point 1 Vulnerable Any minor. Adult who 1) demonstrates limitations in decision making capacity and/or 2) is prone to perception of undue infl uence or coercion to participate. 2 points TOTAL: 3 The Level of Overall Risk of your Study is: Low : 3 or 4 points Moderate : 5 points High : 6 to 10 points If the investigator feels that the score does not reflect the risk appropriately, he/she may provide a rationale justifying a different risk level in Part II, item 2 of the DSMP form.

PAGE 156

156 APPENDIX H ALTERNATIVE RECRUITMENT STRATEGY Alternative Recruitment Strategy If by the end of the fi rst month of data collection, 34 participants have not completed the survey, the PI will consider recruiting the participants in person. Service member s may respond more favorably to another service member participate. The private venue for service member s to make the decision to participate or not participate will be maintained in order to ensure that service member s understand th at participating is voluntary. The PI realizes that this alternative strategy will not permit blinding of the researcher and complete anonymity. However, confidentiali ty can still be maintained especially since no identifying information will be included on any of the response forms. The details of the Alternative Recruitment Strategy are listed below. Alternative Screening and Recruitment Procedures Screening for in clusion in the study and recruitment will take place at the conclusion of the Navy mandated physical and psychological screening interview, which is recorded on DD FORM 2900 (PDHRA) and supplemented with the PCL M form at the DHC. Responses on DD FORM 290 0 and the PCL M provide the interviewer with the majority of necessary information to make inclusion/exclusion decisions. The recruitment coordinator (PA) will view the form but not extract data to minimize the effort of the recruitment coordinator so as n ot to impact on their ability to complete their regular mission of identifying the physical and mental health needs of service member s and referring them as necessary. The recruitment coordinator will use the Alternative Participant Inclusion/Exclusion Sc reening Flow Sheet (below) to guide decisions on which service member s meet study inclusion/exclusion criteria and which service member s to refer to the PI. All service member s who meet screening criteria will be introduced to the PI (who will be statione d in a room next door) by the recruitment coordinator at the completion of the PDHRA The PI will use the Alternative Script for Introducing the Study (below) to complete the screening and recruitment process. Alternative Informed Consent Process All se rvice member s who meet inclusion criteria will be provided with the participant information sheet (Appendix C) that contains a written description of the study including the study purpose, procedures, duration, risks, benefits, and the right to withdraw at any time without penalty. They will also be provided a list of deployment related resources (Appendix D), and a study packet that contains the study questionnaires (Appendix E ). Service member will be answered. C ompleting and returning the study questionnaires will serve as documentation of implied informed consent. Alternative Data Collection Process Once all questions and concerns are addressed, the PI will escort the service member to the data collection room direct attention to the location of the file cabinet, and then leave. Participants can decide to complete the study packet or not complete the study packet and place either the completed or the non completed forms in the locked file cabinet.

PAGE 157

157 The inves tigator will collect completed surveys from the file cabinet at the end of each data collection day. This process will continue until 123 participants who meet inclusion criteria have completed the survey.

PAGE 158

158 Alternative Participant Inclusion/Exclusion Scre ening Flow Sheet C ompleting PDHRA? Do NOT Refer to PI NO Do NOT Refer to PI Active Duty Navy (DD FORM 2900, pg 1)? NO YES YES YES Total PCL M score > 50? NO At least 1 reexperiencing symptom on PCL M at moderate level or above? (item #s 1 5) At least 3 avoidant/numbing symptoms on PCL M at moderate level or above? (item #s 6 12) At least 2 hyperarousal sympt oms on PCL M at moderate level or above? (item #s 13 17) NO NO NO YES YES YES Do NOT Refer to PI Does service member pose a current risk for harm to self or others (DD FORM 2900, pg 4, #3a)? Do NOT Refer to PI YES NO REFER to PI

PAGE 159

159 Alternative Script for Introducing the Study The commanding officer of the Naval Hospital has given permission to me, LCDR Cunningham, to conduct a resea rch study here at the Deployment Health Center. I am a Duty Under Instruction (DUINS) doctoral student at the College of Nursing at the University of Florida. I am conducting a research study related to post deployment adjustment experiences. Study par ticipation involves completing a written survey that is expected to take between 18 to 22 minutes of your time. Here is a description of the study (hand the Please read t he Study Introduction Information Sheet. After the service member is finished reading, ask if they have any questions. If service member has met all inclusion/exclusion criteria contained on the DD FORM 2900 and the PCL M, the recruitment coordinator will then introduce the service member t o the PI: IF Service member answers YES then answer their questions. IF Service member answers NO or once all of their questions have been answered, then escort the service member to the data collection room and read the following: If you decide to p articipate, please complete the study questionnaires and place them through a slot into a locked file cabinet (direct service members attention to the file cabinet) Your decision about participating in this study is confidential. If you decide to partici pate, complete the survey and deposit it in the metal file cabinet and then leave. If you decide not to participate, leave your survey blank and deposit it in the metal file cabinet and then leave.

PAGE 160

160 LIST OF REFERENCES Adler, A. B., Bliese, P. D., & Castro, C. A. (2011). Deployment Psychology: Evid ence Based Strategies to Promote Mental Health in the Military Washington, DC: American Psychological Association. Adler, A. B., Bliese, P. D., McGurk, D., Hoge, C. W., & Castro, C. A. (2009). Battlemind Debriefing and Battlemind Training as Early Interve ntions With Soldiers Returning From Iraq: Randomization by Platoon. Journal of Consulting and Clinical Psychology, 77, 928 940. Barchard, K. A., Scott, J., Weintraub, D., & Pace, L. A. (2008). Better Data Entry: Double Entry is Superior to Visual Checking. In American Psychological Association Annual Convention Black, J. S., Gregersen, H. B., & Mendenhall, M. E. (1992). Toward A Theoretical Framework of Repatriation Adjustment. Journal of International Business Studies, 23, 737 760. Blais, A. R., Thompson, M. M., & McCreary, D. R. (2009). The Development and Validation of the Army Post Deployment Reintegration Scale. Military Psychology, 21, 365 386. Bliese, P. D., Wright, K. M., Adler, A. B., Cabrera, O., Castro, C. A., & Hoge, C. W. (2008). Validating the primary care posttraumatic stress disorder screen and the posttraumatic stress disorder checklist with soldiers returning from combat. Journal of Consulting and Clinical Psychology, 76, 272 281. Bonanno, G. A. (2004). Loss, trauma, and human resilience Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20 28. Booth Kewley, S., Larson, G. E., Highfill McRoy, R. M., Garland, C. F., & Gaskin, T. A. (2010). Correlates of Posttraumatic Stress Disord er Symptoms in Marines Back From War. Journal of Traumatic Stress, 23, 69 77. Bowles, S. V. & Bates, M. J. (2010). Military Organizations and Programs Contributing to Resilience Building. Military Medicine, 175, 382 385. Bowling, U. B. & Shermian, M. D. (2 008). Welcoming them home: Supporting service members and their families in navigating the tasks of reintegration. Professional Psychology Research and Practice, 39, 451 458. Bragin, M. (2010). Can Anyone Here Know Who I Am? Co constructing Meaningful Narr atives With Combat Veterans. Clinical Social Work Journal, 38, 316 326.

PAGE 161

161 Brenner, L. A., Gutierrez, P. M., Cornette, M. M., Betthauser, L. M., Bahraini, N., & Staves, P. J. (2008). A qualitative study of potential suicide risk factors in returning combat ve terans. Journal of Mental Health Counseling, 30, 211 225. Bryant, R. A. (2003). Early predictors of posttraumatic stress disorder. Biological Psychiatry, 53, 789 795. Butterfield, P. G., Yates, S. M., Rogers, B., & Healow, J. M. (2003). Overcoming subject recruitment challenges: Strategies for successful collaboration with novice research agencies. Applied Nursing Research, 16, 46 52. Cantrell, B. C. & Dean, C. (2005). Down Range: To Iraq and back Seattle: Wordsmith Books. Cantrell, B. C. & Dean, C. (2007) Once A Warrior: Wired for Life Seattle: Wordsmith Books. Charuvastra, A. & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual Review of Psychology, 59, 301 328. Connor, K. M. & Davidson, J. R. T. (2003). Development of a new resi lience scale: The Connor Davidson Resilience scale (CD RISC). Depression and Anxiety, 18, 76 82. Cummings, J. & Masten, J. (1994). Customized dual data entry for computerized data analysis. Quality Assurance, 3, 300 303. Doyle, M. E. & Peterson, K. A. (200 5). Re entry and reintegration: Returning home after combat. Psychiatric Quarterly, 76, 361 370. Engdahl, B., Dikel, T. N., Eberly, R., & Blank, A. (1997). Posttraumatic stress disorder in a community group of former prisoners of war: A normative response to severe trauma. American Journal of Psychiatry, 154, 1576 1581. Erdfelder, E., Faul, F., & Buchner, A. (1996). GPOWER: A general power analysis program. Behavior Research Methods Instruments & Computers, 28, 1 11. Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41, 1149 1160. Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical power a nalysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175 191. Field, A. (2005). Discovering statistics using SPSS (2 ed.) London: Sage.

PAGE 162

162 Figley, C. R. & Nash, W. P. (2007). Combat Stress Injury: Theory, Resear ch, and Management NY: Routledge. Findley, T. W. & Stineman, M. G. (1989). Research in Physical Medicine and Rehabilitation .5. Data Entry and Early Exploratory Data Analysis. American Journal of Physical Medicine & Rehabilitation, 68, 240 251. Furukawa, T. (1997). Sojourner readjustment Mental health of international students after one year's foreign sojourn and its psychosocial correlates. Journal of Nervous and Mental Disease, 185, 263 268. Gambardella, L. C. (2008). Role exit theory and marital disco rd following extended military deployment. Perspectives in Psychiatric Care, 44, 169 174. Guay, S., Billette, V., & Marchand, A. (2006). Exploring the links between posttraumatic stress disorder and social support: processes and potential research avenues. Journal of Traumatic Stress, 19, 327 338. Haas, D. A. & Pazdernik, L. A. (2006). A cross sectional survey of stressors for postpartum women during wartime in a military medical facility. Military Medicine, 171, 1020 1023. Haglund, M. E. M., Nestadt, P. S. Cooper, N. S., Southwick, S. M., & Charneya, D. S. (2007). Psychobiological mechanisms of resilience: Relevance to prevention and treatment of stress related psychopathology. Development and Psychopathology, 19, 889 920. Hart, A. B. (2000). An operators manual for combat PTSD; Essays for coping Lincoln, NE: Writer's Digest. Herman, J. L. & Tetrick, L. E. (2009). Problem Focused Versus Emotion Focused Coping Strategies and Repatriation Adjustment. Human Resource Management, 48, 69 88. Hill, J. J., Mobo, B H. P., & Cullen, M. R. (2009). Separating Deployment Related Traumatic Brain Injury and Posttraumatic Stress Disorder in Veterans Preliminary Findings from the Veterans Affairs Traumatic Brain Injury Screening Program. American Journal of Physical Medici ne & Rehabilitation, 88, 605 614. Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295, 1023 1032.

PAGE 163

163 Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351, 13 22. Holmes, T. H. & Rahe, R. H. (1967). Social Readjustment Rating Scale. Journal of Psychosomatic Research, 11, 213 &. Hubal, R. C. & Day, R. S. (2006). Informed consent procedures: An experimental test using a virtual character in a dialog syst ems training application. Journal of Biomedical Informatics, 39, 532 540. Institute of Medicine (2010). Returning home from Iraq and Afghanistan: Preliminary assessment of readjustment needs of veterans, service members, and their families Washington, DC: National Academies Press. Johnson, D. R., Lubin, H., Rosenheck, R., Fontana, A., Southwick, S., & Charney, D. (1997). The impact of the homecoming reception on the development of posttraumatic stress disorder: The West Haven Homecoming Stress Scale (WHHSS ). Journal of Traumatic Stress, 10, 259 277. Kaspersen, M., Matthiesen, S. B., & Gotestam, K. G. (2003). Social network as a moderator in the relation between trauma exposure and trauma reaction: a survey among UN soldiers and relief workers. Scandinavian Journal of Psychology, 44, 415 423. Katz, L. S., Cojucar, G., Davenport, C. T., Pedram, C., & Lindl, C. (2010). Post Deployment Readjustment Inventory: Reliability, Validity, and Gender Differences. Military Psychology, 22, 41 56. Kawado, M., Hinotsu, S., Matsuyama, Y., Yamaguchi, T., Hashimoto, S., & Ohashi, Y. (2003). A comparison of error detection rates between the reading aloud method and the double data entry method. Controlled Clinical Trials, 24, 560 569. Kaylor, J. A., King, D. W., & King, L. A. (1 987). Psychological Effects of Military Service in Vietnam A Metaanalysis. Psychological Bulletin, 102, 257 271. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic Stress Disorder in the National Comorbidity Survey Archives of General Psychiatry, 52, 1048 1060. King, D. W., King, L. A., Foy, D. W., Keane, T. M., & Fairbank, J. A. (1999). Posttraumatic stress disorder in a national sample of female and male Vietnam veterans. Risk factors, war zone stressors, and res ilience recovery variables. Journal of Abnormal Psychology, 108, 164 170.

PAGE 164

164 King, D. W., King, L. D., Gudanowski, D. M., & Vreven, D. L. (1995). Alternative Representations of War Zone Stressors Relationships to Posttraumatic Stress Disorder in Male and Fe male Vietnam Veterans. Journal of Abnormal Psychology, 104, 184 196. King, D. W., Taft, C., King, L. A., Hammond, C., & Stone, E. R. (2006). Directionality of the association between social support and posttraumatic stress disorder: A longitudinal investig ation. Journal of Applied Social Psychology, 36, 2980 2992. King, L. A., King, D. W., Vogt, D. S., Knight, J., & Samper, R. E. (2006). Deployment risk and resilience inventory: A collection of measures for studying deployment related experiences of militar y personnel and veterans. Military Psychology, 18, 89 120. Kratochwill, T. R., Elliott, S. N., & Busse, R. T. (1995). Behavior Consultation A 5 Year Evaluation of Consultant and Client Outcomes. School Psychology Quarterly, 10, 87 117. Litz, B. T. (2007) Research on the impact of military trauma: Current status and future directions. Military Psychology, 19, 217 238. Litz, B. T. & Roemer, L. (1996). Post traumatic stress disorder: An overview. Clinical Psychology & Psychotherapy, 3, 153 168. Litz, B. T. (2004). Early intervention for trauma and traumatic loss New York: Guilford Press. MacDermid Wadsworth, S. M. (2010). Family risk and resilience in the context of war and terrorism. Journal of Marriage and Family, 72, 537 556. Martin, C. B. (2007). Routin e screening and referrals for PTSD after returning from Operation Iraqi Freedom in 2005, U.S. Armed Forces. Medical Surveillance Monthly Report, 14, 2 7. McPherson, F. & Schwenka, M. A. (2004). Use of complementary and alternative therapies among active du ty soldiers, military retirees, and family members at a military hospital. Military Medicine, 169, 354 357. Meleis, A. I. (2007). The disicpline of Nursing: A perspective, a domain, and definitions. In Theoretical Nursing: Development and progress (4 ed., pp. 453 485). Philadelphia, PA: Lippincott Williams & Wilkins. Meyers, L. S., Gamst, G., & Guarino, A. J. (2006). Applied multivariate research: Design and interpretation Thousand Oaks, CA: Sage.

PAGE 165

165 Milliken, C. S., Auchterlonie, J. L., & Hoge, C. W. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq war. Journal of the American Medical Association, 298, 2141 2148. National Center for PTSD (2005). Returning from the war zone: A guide f or military personnel National Center for PTSD. Newby, J. H., McCarroll, J. E., Ursano, R. J., Fan, Z., Shigemura, J., & Tucker Harris, Y. (2005). Positive and negative consequences of a military deployment. Military Medicine, 170, 815 819. Pietrzak, R. H ., Goldstein, M. B., Malley, J. C., Johnson, D. C., & Southwick, S. M. (2009). Subsyndromal Posttraumatic Stress Disorder Is Associated with Health and Psychosocial Difficulties in Veterans of Operations Enduring Freedom and Iraqi Freedom. Depression and A nxiety, 26, 739 744. Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., Rivers, A. J., Morgan, C. A. et al. (2010). Psychosocial buffers of traumatic stress, depressive symptoms, and psychosocial difficulties in veterans of Operations Enduri ng Freedom and Iraqi Freedom: The role of resilience, unit support, and postdeployment social support. Journal of Affective Disorders, 120, 188 192. Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., & Southwick, S. M. (2009). Psychological Resilience and Postdeployment Social Support Protect Against Traumatic Stress and Depressive Symptoms in Soldiers Returning from Operations Enduring Freedom and Iraqi Freedom. Depression and Anxiety, 26, 745 751. Portney, L. G. & Watkins, M. P. (2009). Fou ndations of clinical research: Applications to practice (3 ed.) Upper Saddle River, NJ: Pearson Education. Rahe, R. H., Mahan, J. L., & Arthur, R. J. (1970). Prediction of Near Future Health Change from Subjects Preceding Life Changes. Journal of Psychoso matic Research, 14, 401 &. Richardson, G. E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58, 307 321. Roberts, B. L., Anthony, M. K., Madigan, E. A., & Chen, Y. (1997). Data management: Cleaning and checking. Nursin g Research, 46, 350 352. Rona, R. J., Hyams, K. C., & Wessely, S. (2005). Screening for psychological illness in military personnel. Jama Journal of the American Medical Association, 293, 1257 1260.

PAGE 166

166 Rutter, M. (1985). Resilience in the Face of Adversity Protective Factors and Resistance to Psychiatric Disorder. British Journal of Psychiatry, 147, 598 611. Ruzek, J. I., Schnurr, P. P., Vasterling, J. J., & Friedman, M. J. (2011). Caring for Veterans with Deployment Related Stress Disorders: Iraq, Afghanist an, and Beyond Washington, DC: American Psychological Association. Sayer, N. A., Noorbaloochi, S., Frazier, P., Carlson, K., Gravely, A., & Murdoch, M. (2010). Reintegration Problems and Treatment Interests Among Iraq and Afghanistan Combat Veterans Recei ving VA Medical Care. Psychiatric Services, 61, 589 597. Sayers, S. L., Farrow, V. A., Ross, J., & Oslin, D. W. (2009). Family Problems Among Recently Returned Military Veterans Referred for a Mental Health Evaluation. Journal of Clinical Psychiatry, 70, 1 63 170. Sayers, S. L., Farrow, V. A., Ross, J., & Oslin, D. W. (2009). Family Problems Among Recently Returned Military Veterans Referred for a Mental Health Evaluation. Journal of Clinical Psychiatry, 70, 163 170. Schlossberg, N. K. (1981). A Model for An alyzing Human Adaptation to Transition. Counseling Psychologist, 9, 2 18. Schneider, J. K. & Deenan, A. (2004). Reducing quantitative data errors: Tips for clinical researchers. Applied Nursing Research, 17, 125 129. Scully, J. A., Tosi, H., & Banning, K. (2000). Life event checklists: Revisiting the social readjustment rating scale after 30 years. Educational and Psychological Measurement, 60, 864 876. Sharkansky, E. J., King, D. W., King, L. A., Wolfe, J., Erickson, D. J., & Stokes, L. R. (2000). Coping w ith Gulf War combat stress: Mediating and moderating effects. Journal of Abnormal Psychology, 109, 188 197. Shea, M. T., Vujanovic, A. A., Mansfield, A. K., Sevin, E., & Liu, F. J. (2010). Posttraumatic Stress Disorder Symptoms and Functional Impairment Am ong OEF and OIF National Guard and Reserve Veterans. Journal of Traumatic Stress, 23, 100 107. Slone, L. & Friedman, M. J. (2008). After the War Zone: A Practical Guide for Returning Troops and Their Families Philadelphia: Da Capo Press. Southwick, S. M., Vythilingam, M., & Charney, D. S. (2005). The psychobiology of depression and resilience to stress: Implications for prevention and treatment. Annual Review of Clinical Psychology, 1, 255 291.

PAGE 167

167 Sterling Turner, H. E., Watson, T. S., & Moore, J. W. (2002). The effects of direct training and treatment integrity on treatment outcomes in school consultation. School Psychology Quarterly, 17, 47 77. Sterling Turner, H. E., Watson, T. S., Wildmon, M., Watkins, C., & Little, E. (2001). Investigating the relationshi p between training type and treatment integrity. School Psychology Quarterly, 16, 56 67. Stringham, E. M. (1993). The Reacculturation of Missionary Families A Dynamic Theory. Journal of Psychology and Theology, 21, 66 73. Sussman, N. M. (2000). The dynam ic nature of cultural identity throughout cultural transitions: Why home is not so sweet. Personality and Social Psychology Review, 4, 355 373. Sussman, N. M. (2001). Repatriation transitions: psychological preparedness, cultural identity, and attributions among American managers. International Journal of Intercultural Relations, 25, 109 123. Sussman, N. M. (2002). Testing the cultural identity model of the cultural transition cycle: sojourners return home. International Journal of Intercultural Relations, 26, 391 408. Suter, W. N. (1987). Approaches to Avoiding Errors in Data Sets A Technical Note. Nursing Research, 36, 262 263. Szkudlarek, B. (2010). Reentry A review of the literature. International Journal of Intercultural Relations, 34, 1 21. Tanielian T. J. L. H. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery Santa Monica, CA: RAND Center for Military Health Policy Research. Thompson, K. E., Vasterling, J. J., Benotsch, E. G. Brailey, K., Constans, J., Uddo, M. et al. (2004). Early symptom predictors of chronic distress in Gulf War veterans. Journal of Nervous and Mental Disease, 192, 146 152. Trent, L., Stander, V., Thomsen, C., & Merrill, L. (2007). Alcohol abuse among U.S. Navy recruits who were maltreated in childhood. Alcohol and Alcoholism, 42, 370 375. Vogt, D. S., Proctor, S. P., King, D. W., King, L. A., & Vasterling, J. J. (2008). Validation of Scales From the Deployment Risk and Resilience Inventory in a Sample of O peration Iraqi Freedom Veterans. Assessment, 15, 381 403.

PAGE 168

168 Walsh, F. (1996). The concept of family resilience: Crisis and challenge. Family Process, 35, 261 281. Watson, C. G., Brown, K., Kucala, T., Juba, M., Davenport, E. C., & Anderson, D. (1993). 2 Stud ies of Reported Pretraumatic Stressors Effect on Posttraumatic Stress Disorder Severity. Journal of Clinical Psychology, 49, 311 318. Waysman, M., Schwarzwald, J., & Solomon, Z. (2001). Hardiness: an examination of its relationship with positive and negati ve long term changes following trauma. Journal of Traumatic Stress, 14, 531 548. Wolfe, J., Proctor, S. P., Davis, J. D., Borgos, M. S., & Friedman, M. J. (1998). Health symptoms reported by Persian Gulf War veterans two years after return. American Journa l of Industrial Medicine, 33, 104 113. Woodruff, S. I. & Conway, T. L. (1994). United States Navy Health Surveillance .2. Responses to A Health Promotion Tracking Survey. Military Medicine, 159, 32 37. Wright, K. M., Bliese, P. D., Adler, A. B., Hoge, C. W., Castro, C. A., & Thomas, J. L. (2005). Screening for psychological illness in the military. Jama Journal of the American Medical Association, 294, 42 43. Yerkes, S. A. & Holloway, H. C. (1996). War a nd homecomings: The stressors of war and of returning from war. In R.J.Ursano & A.E.Norwood (Eds.), Emotional aftermath of the Gulf War (pp. 25 42). Washington, DC: American Psychiatric Press.

PAGE 169

169 BIOGRAPHICAL SKETCH Cra ig Andrew Cunningham was born in Omaha, Nebraska. One of five children, he grew up mostly in Ashland, Nebraska graduating from Ashland Greenwood High School i n 1986. He earned his B.A. in psychology and his B.S. in n ursing from University of Nebraska in 1992 and 1995, respectively. U pon graduating in 1995, Craig entered the active duty Navy as an Ensign. As a assignments took him to South Carolina, Virginia, and Florida working in a variety of roles as a Medical Surgical Nurse, Perioperative Nurse, and Director and instructor for selected for Duty Under Instruction and attended Hampton University where h e earned his M.S. i n nursing administration and e ducation in 2004. While stationed in Florida, Craig was again selected for Duty Under Instruction, his current assignment, which allowed him the opportunity to earn his PhD in nursing s cience s at the University of Florida. Up on completion of his PhD program, Craig will be assigned to Naval Medical Center Portsmouth, VA.