A Mixed Methods Approachto Study Health of

Veterans Home from War

LisaMarie Wands, PhD, RNVA Quality Scholar Fellow

Tennessee Valley Healthcare SystemVanderbilt University

Acknowledgements

• Funded by Florida Nurses Foundation• Completed at Florida Atlantic University, Boca

Raton, FL– Dissertation committee chair: Pat Liehr, PhD, RN

Objectives

• Describe the deliberative process of choosing multiple methods to study the phenomenon of coming home from war

• Report results of mixed methods study of veteran health

Background• 2.4 military personnel have deployed to Iraq and

Afghanistan since September 11, 2001• Only about 50% of eligible veterans have accessed VA

health care• 93% are 51 years of age or younger; 46.8% 31 years of age

or younger• Often discussed in literature by specific diagnoses (i.e.,

PTSD)

Spelman, Hunt, Seal, & Burgo-Black, (2012)

Purpose/Aims• Explore the health experience of coming home from

war for OEF/OIF veterans• Specific aims:– Describe complicating health issues– Describe movement toward resolving– Identify dimensions of health– Explore similarities and distinctions between these elements

Why Mix Methods?• Nontraditional population requiring care– Physically fit (unless injured)– Young– Generally targeted for preventive care and education

• Complex health needs– Deployment to combat zone can affect all realms of

health

Qualitative Approach

• Story inquiry method– Health challenge: coming home from war– Complicating health issues– Movement toward resolving

Liehr & Smith, (2008)

Quantitative Approach• Short-Form Health Survey, Version 2 (SF-36v2)– Two summary scales

-Overall physical health-Overall mental health

– Eight subscales-Physical functioning -Social functioning-Performance in physical role -Bodily pain-Performance in emotional role -General health perceptions-Vitality -Mental health

Recruitment• FAU IRB approval obtained to study FAU students who are

veterans• Inclusion criteria– Served in any branch of the U.S. Armed Forces– Deployed to Iraq or Afghanistan since September 2011– 21 years of age or older– Students at Florida Atlantic University– Able to speak and read English– Consent

Mixing Methods

• Creswell’s (2003) criteria– Implementation– Priority– Integration– Theoretical perspective

ImplementationIn what sequence will data be collected?

• Cross-sectional design; all data collected during one session– Demographic data collected first– Qualitative interview conducted– Participant completed SF-36v2 instrument

PriorityWill one type of data be given more weight

than another?

• Objective was to explore and describe• Qualitative data were given more weight• Intended sample size was small

IntegrationHow and when will data be combined?

• Qualitative data analyzed using an inductive approach

• Quantitative data analyzed using the QualityMetric Health Outcomes ™ Scoring Software, Version 4.0

• Comparisons in findings made

Theoretical PerspectiveIs a theoretical perspective being used

to guide this study?

• Wholeness of persons• Story theory– Story is a narrative happening of connecting with

self-in-relation through intentional dialogue to create ease

Congruence of Methods

Sample• 7 participants– 6 male; 1 female– 3 married; 4 single– 2 Hispanic; 5 non-Hispanic– 1 Asian; 6 White– 2 Army; 2 Marines; 1 Marines Reserve; 2 Navy– Ages ranged 24-28– Length of military service ranged 4-6 years– Time home range 1-8.6 years; average 3.6 years

Findings• Qualitative– Complicating health issues– Movement toward resolving

• Quantitative– Dimensions of health

• Mixing methods– Similarities/Distinctions

Complicating Health IssuesFlipping the switchMoving from the strict regimentation and vigilance of military life to the everydayness of civilian life

Figuring out how to belongIdentifying new patterns within existing relationships

Living the stress of a new normalNegotiating the tension between gains and losses in the process of transitioning

Movement toward ResolvingConnecting with othersValuing existing formal and informal relationships and relying on them for comfort and encouragement

Choosing a positive attitudeFacing the day with an optimistic outlook and an eye to the future

Dimensions of Health

PF = physical functioning; RP = role-physical; BP = bodily pain; GH = general health; VT = vitality; SF = social functioning; RE = role-emotional; MH = mental health

Health Dimensions of the SF-36v2

PF RP BP SF RE MH

Complicating Health Issues

Flipping the switch X X X

Figuring out how to belong X X X

Living the stress of a new normal X X X

Movement toward Resolving

Connecting with others X X X

Choosing a positive attitude X X X X

Mixing Methods

Discussion• Participants identified dimensions of health as

physical and mental; however, narrative revealed relationships with self and others as important influencers of health

• Concerns with physical health did not emerge from qualitative data; however, one participant scored very poorly on quantitative physical health measures

Limitations

• Small sample size• Focused perspective of veterans who have

returned to school• Timing of study in relation to experience

Implications• Consider delivery of important post-deployment

education in relation to timing• Educate care providers outside of military/VA venues• Use/Creation of approaches that address social

issues• Study successful strategies• Encourage therapeutic social interaction

References• Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed methods

approaches (2nd ed.). Thousand Oaks, CA: Sage.• Liehr, P., & Smith, M. J. (2007). Story inquiry: A method for research. Archives of

Psychiatric Nursing, 21(2), 120-121.• Smith, M. J., & Liehr, P. (2008). Theory-guided translation: Emphasizing human

connection. Archives is Psychiatric Nursing, 22(3), 175-176.• Spelman, J. F., Hunt, S. C., Seal, K. H., & Burgo-Black, A. L. (2012). Post deployment care

for returning combat veterans. Journal of General Internal Medicine, 27(9), 1200-1209.• Ware, J. E., Kosinski, M., Bjorner, J. B., Turner-Bowker, D. M., Gandek, B., & Marish, M.

E. (2007). User’s manual for the SF-36v2 Health Survey (2nd ed.). Lincoln, RI: QualityMetric.