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Patient Perception, Preference and Participation

Facilitating

culture-centered

communication

between

health

careproviders and veterans transitioning from military deployment tocivilian

life

Christopher J. Koenig a,b,d,*,

Shira Maguen a,c,

Jose D. Monroy a,e,

Lindsay Mayotta,d,Karen H. Seal a,c,d

a San Francisco Veterans Administration Medical Center, San Francisco, USAbPhilip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, USAcDepartment of Psychiatry, University of California, San Francisco, San Francisco, USAdDepartment of Medicine, University of California, San Francisco, San Francisco, USAeDepartment of Psychology, San Francisco State University, San Francisco, USA

1.

Introduction

Approximately 2.4 million United States military personnel

have been deployed to Iraq and Afghanistan since September 11,

2001. Military deployment and combat has historically shown to

result in medical [14], psychological [58], and social problems

[913], all of which affect veterans post-deployment health across

the life course [1316].

Prior research on reintegration among Iraq and Afghanistan

veterans has focused primarily on the physical and psychosocial

problems that arise in the process of re-adjustment, but only a

handful of previous studies focus on the cultural aspects of

reintegration, such as thedifferences betweenmilitary and civilian

social environments [1720]. Faulkner and McGaw [21] propose a

comprehensive model of reentry for Vietnam era veterans using a

three stage model: disengagement from military life; re-entry into

the world of the civilian after deployment; and, full reintegration

into civilian life. We build on this idealized temporal progression

Patient Education and Counseling 95 (2014) 414420

A

R

T

I

C

L

E

I

N

F

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Article history:

Received 6 August 2013

Received in revised form 3 February 2014

Accepted 22 March 2014

Keywords:

Patient-centered care

Health communication

Culture

Post-deployment health

Readjustment experience

Military veterans

USA

A

B

S

T

R

A

C

T

Objective: To describe returning veterans transition experience from military to civilian life and to

educate health care providers about

culture-centered communication that promotes readjustment to

civilian life.

Methods: Qualitative, in-depth, semi-structured interviews with 17 male and 14 female Iraq and

Afghanistanveterans wereaudio recorded, transcribedverbatim,and analyzedusingGrounded Practical

Theory.

Results: Veterans described disorientation when returning to civilian life after deployment. Veterans

experiencesresulted from anunderlyingtensionbetweenmilitary andcivilian identities consistentwith

reverse culture shock. Participants described challenges and strategies formanaging readjustment stressacross three domains: intrapersonal, professional/educational, and interpersonal.

Conclusions: To provide patient-centered care to returning Iraq and Afghanistan veterans, health care

providers must be attuned to medical, psychological, and social challenges of the readjustment

experience, including reverse culture shock. Culture-centered communication may help veterans

integrate positive aspects of military and civilian identities, which may promote full reintegration into

civilian life.

Practice implications: Health care providers may promote culture-centered interactions by asking

veterans to reflect about their readjustment experiences. By actively eliciting challenges and helping

veterans to identify possible solutions, health care providersmay help veterans integrate military and

civilian identities through an increased therapeutic alliance and social support throughout the

readjustment process.

Published

by Elsevier Ireland Ltd.

* Corresponding author at: Department of Medicine, San Francisco Veterans

Administration Medical Center, 4150 Clement Street, 111-A1, San Francisco, CA

94121, USA. Tel.: +1 415 221 4810x6419; fax: +1 415 379 5573.

E-mail address: [email protected] (C.J. Koenig).

Contents lists available at ScienceDirect

Patient Education and Counseling

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0738-3991/Published

by

Elsevier

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Ltd.


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by focusing the experiences of Iraq and Afghanistan veterans as

they re-enter civilian life, but before they fully reintegrate into

civilian life. We investigate reintegration as a complex social and

temporal process [14,22].

Culture is commonly defined as the shared values,perspectives,

and routine, but taken-for-granted, practices within a community

[23,24].

Culture

shapes

heath

and

healthcare

in

diverse

popula-tions and communities as well as the course and outcomes of

various diseases and illness conditions [25,26]. Military veterans

have been widely studied as a community with a distinct and

recognizable culture resulting from participation in both civilian

and military contexts [20,2729], but whose health has been

shown to be particularly vulnerable due to deployment experi-

ences [3032]. Basic military training impacts individual develop-

ment through acculturation into military culture, which affects the

individuals sense of self or identity. However, upon returning

home veterans receive limited or no similar training to acculturate

back to civilian life [33,34]. As a result, many returning Iraq and

Afghanistan veterans face challenges reintegrating into civil

society, including identity conflict, alienation, depression, anxiety,

and interpersonal difficulties [20,3538]. Drawing from the

literature on educational and cross-cultural transition [3941],

Westwood et al. characterize reverse culture shock as a type of

stress associated with unanticipated adjustment difficulties and

unmet expectations by. . .following a re-entry experience [33].

While reverse culture shock has been documented in veterans

historically [10,21,42,43], few empirical studies use this construct

to contextualize post-deployment problems such as physical

chronic pain; psychological feelings of helplessness, irritability,

and moral contamination; and social problems of isolation

[20,22,33,44].

Recognizing these challenges, the Department of Veterans

Affairs (VA) launched the Office of Patient Centered Care and

Cultural Transformation (OPCCCT) to develop and evaluate new

health care models that provide effective and culture-centered

services for veterans. Because health disparities research that

shows ethnic, linguistic, and racialminorities canbeexcluded from

health care processes in large health care organizations [4547],

theOPCCCTmission shifts the significance of culture-centered care

to include all veterans [48], as veteran-provider encounters can be

intercultural due do systematic differences between civilian and

military cultures as well as lay patient and professional medical

cultures [49]. However, little prior research examines the

relationship

between

communication

and

patient-centered

care

using an expanded conception of culture [11,22,33,44].

To fill this knowledge gap, we conducted a qualitative study

with returning Iraq and Afghanistan veterans: (1) to describe the

challenges and opportunities veterans experience when transi-

tioning from military to civilian life; and (2) to develop a

theoretical model that identifies broad cultural domains ofsignificant for veterans readjustment. Our overall goal was to

develop a model of veteran readjustment that is of practical value

to foster culturally sensitive interactions between providers and

veterans after deployment.

2. Methods

We conducted in-depth semi-structured interviews with Iraq

and Afghanistan combat veterans who had returned from

deployment within the last two years. We purposively sampled

veterans who were seen in the Integrated Care, Primary Care, or

Womens clinics at the San Francisco VA Medical Center (SFVAMC)

at least twice within three months between October 31, 2008 and

October 31, 2010. We used administrative data to find veteranswith a positive screen for at least one mental health problem, i.e.,

posttraumatic stress disorder (PTSD), depression, or high-risk

drinking. We focused on Iraq and Afghanistan veterans because

they recently returned from a warzone, have a high prevalence of

mental health problems [50], and under-utilize mental health care,

all of which may hamper readjustment. We over-sampled female

veterans because they represent one of the fastest growing

segments of veterans seeking VA services, and little is known

about

the

unique

challenges

women

veterans

face

in

returninghome [35,51,52]. Eligible veteranswere sent an introduction letter,

a study information sheet, and an opt-out postcard. If the postcard

was not returned within 14 days, veterans were contacted by

telephone to describe the study and to invite participation. The

protocol was approved by the Committee on Human Research at

the University of California, San Francisco and the Research

Protection Programs at the SFVAMC and Department of Defense.

The study team developed an original semi-structured inter-

view guide drawing on the senior authors (KHS) experience as a

primary care physician caring for Iraq and Afghanistan veterans

and the first authors (CJK) expertise in health services research.

The interview began by describing the goal to investigate veterans

readjustment experiences. The interview guide included questions

about challenges associated with readjusting to civilian life

illustrated in Fig. 1. The interview guide was pilot tested over

the first five interviews, and questions were subsequently

prioritized to accommodate participant time constraints [53].

We used the interview as conversation model that emphasizes

interviewing as social interaction, a technique consistent with

investigating lifecourse transitions and culture [54]. During the

interview, if the opportunity arose,wedeviated from the interview

guide to explore novel topics not originally included. For example,

when recounting challenges to reintegration, participants fre-

quently offered advice of what they had found useful or what they

would have liked to have known before returning home. We

speculated that advice giving may be evidence for adaptation to

the challenges of homecoming as a possible indicator for

posttraumatic growth and resilience [55]. As a result, we added

questions to the interview guide that explicitly solicited partici-

pants advice to learn about the range of coping strategies they

employed during the readjustment period.

The first author, a medical sociologist and linguist, conducted

all individual semi-structured interviews over 6 months between

January and July, 2011. Interviews lasted a mean of 63 min

(SD 0.007 min), and were conducted either by telephone (54.8%) or

in person in a private interview room (45.2%) according to participant

preference

[56].

Participants

gave

informed

consent

prior

to

each

interview, and received $30 in compensation for the one-time

interview. Participants gave permission to audio-record interviews,

which

were

professionally

transcribed

verbatim

and

resulted

in

1156

double-spaced

pages

of

transcripts

(mean

length

=

37

pages;

SD

12

pages). We imported all transcripts into ATLAS.ti (v7.1) for qualitative

data management [57].We used Grounded Practical Theory (GPT) [58], to guide the

analysis. GPT employs interpretive analytic methods, such as

theme-oriented discourse analysis [59,60], to theoretically recon-

struct how members language use may construct communication

practices, recurrent social actions, and situated social identities.

The overall goal of GPT is to use empirical evidence to develop

normative theories that are practically useful. To construct our

analysis, we employed the editing approach [53], a multi-step

process that emphasizes a nave orientation to data by focusing on

what may be meaningful to participants rather than what may

have beenmeaningful fromprior research or clinicalperspectives a

priori. For example, when veterans described constantly scanning

the environment for a possible threat, rather than using a technical

term hypervigilence, we used a vernacular term, such as feeling onedge. We first identified explicit interviewer questions about

challenges and advice for returning home and located participants

C.J. Koenig et al./Patient Education and Counseling 95 (2014) 414420 415


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corresponding answers. Resulting question-answer segments

were the unit of analysis [61]. We then applied a provisional

code to each segment that broadly classified it as a challenge or

advice [62]. The authorship team reviewed segments across

interviews to create a preliminary inventory of all challenges

and advice. Next, we reviewed each segment for sub-classification

into non-mutually exclusive codes that captured participants

points of view, which was subsequently reviewed by the team.

Once all initially identified segmentswere sub-coded, we returned

to the original transcripts to search for additional instances of

challenges and advice elicited in the course of answering other

questions, iteratively adding codes as necessary to account

comprehensively for all segments. Throughout this process,

particularly information rich segments were assigned a unique

identifier, annotated, and iteratively reviewed for reporting. We

achieved theoretical saturation after identifying 278 segments,

which we defined as not adding new or additional dimensions to

the

emerging

analysis

[63].

Quotations

are

anonymized

and

edited

for clarity.

3.

Results

and

analysis

Of the 73 total eligible veterans contacted by mail, 31 (42.5%)

were interviewed. Forty-two veterans did not participate for thefollowing reasons: couldnotbe reached for follow-upby telephone

(n = 30); declined to be interviewed due to lack of time (n = 6) or

interest (n = 3), or failed to participate in a scheduled interview

(n = 3). Participants median age was 30 years old, 45.2% were

female, and 19 were members of diverse racial/ethnic groups

summarized in Table 1. All active military branches were

represented except Coast Guard. Except for the finding that

women were significantly more likely to participate, no statisti-

cally significant differences were discernible demographically,

including age, ethnicity, rank, military branch, number of

deployments.

Returning Iraq and Afghanistan veterans described various

challenges when readjusting to civilian life after deployment. All

veterans reported feeling once-familiar aspects of their civilianlives were altered no veteran returned home unchanged. In Fig. 2

we theorize that when describing the challenges of and offering

advice about their readjustment experience, veterans articulate an

implicit tension between military and civilian identities across

three interrelated cultural domains.Wespeculate this tensionmay

be due to perceived differences between military and civilian

cultures after returning home from military deployment.

3.1.

The

intrapersonal

domain

Participants identified several intrapersonal psychological

challenges they experienced in their transition from military to

civilian cultures. For example, service members are trained in

critical survival skills in a war zone, such as being on guard and

vigilant about their surrounding environment at all times. In

response to the interviewers (IVR) question, the veteran (VET)

describes adjusting back to civilian life after military deployment.

Extract 1. [29:4] Army, Female, Hispanic, 2630 years old.

IVR What was it like transitioning back to civilian life after being deployed?

VET Itwasweird.Justdriving, itwas just crazybecausewhen yougo to switch

lanes, you just see something on the street that I think is an IED

[improvised explosive device]. So its like, Iwas always alert even when I

came back. The neighbor down stairs slammed the door one night, and I

thought it was a bomb and I started looking for an IBA [Interceptor Body

Armor], my weapon.

In this case, unfamiliar objects in the street or unanticipated

loud sounds evoke the war zone. Other participants recounted

similar experiences of reaching for military equipment, such as a

firearm, helmet orbody armor, when surprised or caught off guard.

Because these skills are continuously practiced and reinforced

during deployment, on their return home, it is difficult to simply

stop being vigilant, despite the absence of obvious external

threat. Thus, survival skills that were highly valued in the warzone

can be maladaptive at home and contribute to mental health

problems.

3.2. The professional/educational domain

Participants also faced challenges associated with theirprofessional and educational lives. While serving, active duty

service members typically experience tight-knit social support

snoitseuQralpmexEniamodweivretnI

Eliciting re-adjustment

challenges How long have you been back home?

Can you tell me a little about your experience coming back

home?

What has been the best thing about coming home for you?

What has been the most challenging thing about coming

home for you?

What are some of the major problems facing Iraq and

Afghanistan veterans when they return home?

What resources have been the most helpful for you in

making the transition back home?

Have there been specific people in your life that have beenhelpful in making the transition to civilian life?

Educing posttaumatic

growth Imagine you are talking with a buddy who is still in the

military and about to come home, what advice would you

give her or him?

What advice would you liked to have heard before coming

home?

What advice would you give someone who has had

challenges similar to yours?

Suppose a buddy just came home, and you learned s/he was

having trouble coping with everyday life. What might you

say? Have you had trouble coping yourself? If so, how didyou handle it?

Fig. 1. Questions from the semi-structured interview guide about readjustment experiences from military deployment to civilian life.

C.J. Koenig et al./Patient Education and Counseling 95 (2014) 414420416


5/8


from fellow soldiers who share longworkdays, living quarters, and

a shared sense of meaningful work. In the following extract , the

participant contrasts her workplace camaraderie as a military

versus civilian nurse:

Extract 2. [26:3] Army, Female, Caucasian, 3135 years old.

IVR What were some of the major challenges that you faced when you came

back?VET Boredom. You know, [during deployment] you function at such a high

level of like, Whats gonna happen? Whats gonna happen? Even

though we were totally burned [out] and exhausted from the amount of

hours and time that we worked. . .But when I went back to my old job,

working on the maternity floor, I found it hard to even like stay awake at

work ((laughter)). I didnt feel like I had anyjob satisfaction. I didnt feel

like we had any camaraderie.

In the military, this veterans work was fast-paced and fostered

a sense of connectedness and shared purpose. By comparison, her

civilianjob in an inpatientmaternityunit wasboth slow-paced and

socially isolated. This shift from high- to low-intensity work, as

well as a lack of meaningful rapport with colleagues negatively

impacted her job satisfaction. Additionally, participants pursuing

college education emphasized the slow pace of traditional

academic environments compared to active duty deployment.

3.3.

The

interpersonal

domain

Returning veterans reported feeling socially isolated both

from military and civilian social networks. Serving one or more

deployments physically separates service members from their

close social networks and creates psychological distance

from events that happened at home, as the following extract

shows:

Extract 3. [18:4] Air Force, Female, Pacific Islander, 2630 years old.

IVR Lets shift a little bit what was it like coming back home for you?

VET

It

was

just

different,

because

[I

was]

away

for

months.

So

you

missed

a

lot

of

what

happened

in

the

States.

[For

example]

whats

going

on

is

totally

different, like new music. Then, the people that youre friends with or

your [romantic] relationship are no longer your friends. Youre just

completely out of sync. So, youre just trying to catch up on what you

missed.

Many participants reported feeling out of sync with both the

popular culture and friends at home who continued their

relationships with one another during the veterans military

deployment. While deployed, soldiers felt separated from their

civilian friends and family; once home, veterans felt separated

from the close friends they developed during military service. This

constant sense of separation from social networks creates

psychological distance from the meaningful places and people

in veterans lives, regardless of location.

3.4.

Cultural

resources

for

resilience

Despite a pervasive tension between military and civilian

identities,

participants

advice

described

personalized

copingstrategiesdeveloped in response to the challengesof readjustment.

Whilenot allparticipants gave advicewithin each analyticdomain,

all participants were able to identify some facet of their experience

that fit at least one cultural domain. For example, many veterans

advisedfinding ways to establish continuity between theirmilitary

and civilian lives by applying military values to their everyday

lives:

Extract 4. [6:1] Marines, Male, Multiracial, 2025 years old.

IVR Lets say that you have a buddy about to come home, what advice would

you

give?

Table 1

Selected

characteristics

of

the

sample

(N=31).

Number of participants (%)

Sex

Male

17

(54.8)

Female 14 (45.2)

Age, years old

2025 3 (9.7)

2630 14 (45.2)

3135 7 (22.6)

3640 3 (9.7)

41+ 4 (12.9)

Race/ethnicity

Caucasian/white 12 (38.7)

Multi-racial 7 (22.6)

Hispanic/Latino 6 (19.3)

African American 3 (9.6)

Asian/pacific islander 3 (9.6)

Rank

Enlisted 20 (64.5)

Officer 11 (35.5)

Military Branch

Army 15 (48.4)

Navy 8 (25.8)

Marines 5 (16.1)Air

force

3

(9.7)

Number of deployments

One 18 (58.1)

Two 9 (29.0)

More

than

two

4

(12.9)

Fig. 2. Theoretical relationships among readjustment ideals, participant values, cultural domains, and communication techniques of the readjustment experience for

returning Iraq and Afghanistan veterans.



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VET

You

have

to

be

proactive

about

everything

you

do.

Nobody

is

going

to

help

you

out.

Nobody

knows

exactly

all

the

information

to

give

you.

Nobody can answer your exact question. You have to find that on your

own.

When veterans return home, many have concerns for which

there may be no easy answer. This participant advises returning

veterans

to

be

proactive

after

returning

from

deployment

bydemonstrating courage through actively pursuing answers when

dealing with institutions, such as the VA, in which participants

frequently feltmired. By encouraging his comrades tobeproactive,

this participant emphasizes the practical value of courage in the

face of adversity,which may foster continuity between hismilitary

and civilian identities.

In response to challenges of isolation from families, friends, and

society at large,participants advised returning veterans to rekindle

activities and relationships that were previously meaningful upon

returning home:

Extract 5. [12:1] Army Reserve, Multiracial, Male, 3135 years old.

IVR Do you have advice for somebody still deployed who is about to come

home?

VET Dont go home and sit around and dwell on negative things about whathappened or, you know,negative aspects of life. Even if you dont feel like

it, force yourself to go back and get involvedwith yournormal life.Do the

things you used to enjoy doing, and see people you used to associate

with. If youre religious, definitely make sure you go to church.

Upon returning home, many veterans may dwell on negative

events that happened during military deployment or on negative

aspects of life more generally. While this may be a normal part of

re-adjustment, it may additionally indicate post-deployment

mental

health

problems

such

as

depression,

adjustment

disorder

or PTSD-related avoidance. This veteran encourages other veterans

to force themselves to become actively involved in their

everyday lifeor in community activities, such as church attendance

to find another source of collective camaraderie.

Finally,

in

response

to

unrecognized

mental

health

problems,some participants advocated seeking mental health treatment in

order to address past military experiences that may negatively

affect full engagement in civilian life:

Extract 6. [10:1] Army Reserve, Male, Caucasian, 41 + years old.

IVR Do you have advice that youwould give to soldiers stilldeployed that are

about to come home?

VET Talk to hygiene [mental health], without a doubt. Sit down and unload.

Just

go

through

every

bad

thing

that

happened,

get

it

out,

talk

to

someone.

Youve

got

to

verbalize

it

to

acknowledge

it.

Dont

be

afraid

to

confront it. Youve got to deal with this shit, or its going to bury you

eventually.

This participant strongly advocates talking to hygiene, a

military term referring to mental health care. By confronting

negative experiences veterans can potentially avoid problems thatcould bury them, such as substance abuse, suicide, and justice

involvement. Additionally, byurging veterans to talk aboutnegative

military experiences, thisadvicewas frequently issued toencourage

returning veterans to directly confront the military stigma

frequently associated with mental health during deployment.

4.

Discussion

4.1. Discussion

This qualitative study describes Iraq and Afghanistan veterans

accounts of readjustment to civilian life after military deployment.

Our analysis shows that participants subtly articulate tensions

between military and civilian cultures and their associated socialidentities during readjustment. While our analysis confirms

previous findings, such as the facts that veterans experience social

isolation [4,18,27] and mental health problems after deployment

[5,50], this study contributes new insights into the role of

communication in the readjustment process.

First, our findings suggest that one source of readjustment

difficulty may be due not only to medical and psychological

trauma, but also to reverse culture shock related to the socio-

cultural

differences

between

military

and

civilian

cultures

andtheir associated identities [18,20,22]. As veterans transition from

military to civilian cultures, they create identities tailored to

specific social and cultural contexts [18,42]. For example, military

behavior appropriate during deployment may be inappropriate

upon returning home, suggesting complex sociocultural tensions

between military and civilian identities. Because veteran identity

may be context sensitive, we theorize that helping veterans

integrate identities across contexts may facilitate smooth read-

justment to civilian life after deployment. Our model expands the

notion of reverse culture shock by identifying three cultural

domains within which veterans experienced challenges and

formulated tailored coping strategies. Describing these challenges

and strategies may assist health care providers anticipate stress

associated with unanticipated difficulties throughout the read-

justment process [33]. For example, a health care provider might

explicitly raise the fact that some veteransfind activemilitaryduty

more interesting than a civilian job in order to set realistic

expectations about the differences of work meaningfulness

throughout readjustment back to civilian life.

Second, our study suggests that careful attention to veterans

language use and communication patterns may play a role in

fostering posttraumatic growth after wartime deployment.

Methodologically, our approach emphasized a dual focus on the

content and the social functions of language during the interview

and subsequent analysis. For example, while we started by asking

veterans about the challenges they experienced when they

returned home from deployment, many veterans volunteered

reflections and offered advice for others who might learn from

their experiences. This builds on established discursive research

showing that in response to a personal trouble or complaint,

remedies frequently follow in subsequent talk [64].Advicegiving is

a social action associated with remedying problems or complaints

and is associated with high epistemic authority [65,66] and

cultural communication norms [67]. While not all participants

provided advice within each analytic domain, all participants

identified some facet of their experience that pertained to at least

one

cultural

domain.

However,

a

minority

of

veterans

articulated

coping strategies in all three domains. Attention to these

interactional dynamics during the interview and throughout the

analysis helped us discern the relationships between challenges

and advice to demonstrate that language use is integral to the

social process of readjustment.

Street et al. [68] suggest that communication can affect healththrough both proximal and intermediate outcomes. Our findings

have may have practical value to foster culturally sensitive

interactions between providers and veterans. In Table 2, we

suggest some communication techniques providers canuse to help

veterans to reflect about challenges and opportunities for growth.

Systematic use of these questions may lead to proximal outcomes,

such as increased trust and patient understanding about the

readjustment process and intermediate outcomes, such as adher-

ence and enhanced self-management [69]. Our findings may

additionally play a role in tailoring evidence-based treatments to

preference-sensitive concerns or even to help providers gauge

treatment acceptability for a full range of treatment modalities,

such as complementary and alternative medicine [18,20,22].

This study has several limitations. First, data are limited to 31Iraq and Afghanistan veterans who had documentation of one or

more mental health problem, which may have contributed to the

C.J. Koenig et al./Patient Education and Counseling 95 (2014) 414420418


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reflexive nature of some participant responses. Expanding the data

collection to include veterans without mental health problems

may enrich current findings. Second, the primary data for this

study were qualitative, semi-structured interviews. While inter-

views provide rich descriptions of participants experience, as self-

reported data they are subject to exaggeration or understatement,

participant memory, and personal feelings at the time of the

interview. Mixed-method research designs that combine qualita-

tive and quantitative data may help to mitigate inherent

weaknesses of using a single method. Finally, because Grounded

Practical Theory is an interpretive framework, other interpreta-

tions may be possible.

4.2. Conclusion

The experience ofwar leaves an indeliblemark on veterans over

the course of their lives. While returning veterans often have

recognizable medical and psychological problems, life after

deployment

includes

coping

with

competing

social

identities,

one rooted in military culture and another rooted in civilian

culture, which have been less recognized in prior research.

Clinicians may help veterans achieve successful reintegration by

encouraging integration of positive aspects of their military and

civilian identities as an interactive social process. By recognizing

veterans unique cultural challenges and strategies for resilience,providers may help foster both cultural- and patient-centered care

when transitioning from the warzone back to civilian life during

routine medical encounters. Patient-centered care is premised on

the ability of patients to be at the center of care, which requires

that providers understand differences between military and

civilian cultures, the readjustment process, and veterans cultural

capacity for resilience.

4.3. Practice implications

While providers may be familiar with medical and psychologi-

cal aspects of post-deployment health, the socio-cultural facets of

veteran readjustment may be less familiar. Our analysis uses

interviews with veterans to identify and describe veteransexperiences of readjusting to civilian life after military deploy-

ment. Our model contributes to practical theory because health

care providers can use thismodel to encourage culturally-sensitive

interactions. For example, the model provides both a framework to

recognize the impact of military and civilian cultures on veteran

post-deployment health and a set of techniques to encourage

posttraumatic growth through reflective communication practice.

Our model may help providers activate veterans endogenous

cultural resources for integrating military and civilian identities

over time that could contribute tohighqualityhealth care andmay

ultimately help promote full reintegration into civilian life after

war.

Funding

Department of Defense award W81XWH-08-2-0106 funded

this study. The funders had no role in the design, data analysis,

writing or approval of the manuscript.

Conflicts of interest

We declare that none of the authors have conflicts of interest.

Acknowledgements

Contributors:

Mr.

Greg

Cohen,

Mr.

Aaron

Daly,

and

Ms.

Emily

Medina for logistical support in the conduct of the study.Wewould

like to thank Drs. Robert Craig and Karen Tracy for their advice

applyingGrounded Practical Theory. Finally,we thank all OEF/OIF/

OND veterans for volunteering to participate in this study, and we

acknowledge their service to our country. We thank the anony-

mous reviewers for playing an active role in collaboratively

shaping the argument for dissemination.

References

[1] BelangerHG,UomotoJM, Vanderploeg RD. The veterans health administrationsystem of care for mild traumatic brain injury: costs, benefits, and controver-sies. J Head Trauma Rehabil 2009;24(1):413. English.

[2]

Pietrzak

RH,

Johnson

DC,Goldstein

MB,Malley

JC,

Southwick

SM. Posttraumaticstress disorder mediates the relationship between mild traumatic brain injury

and

health

and

psychosocial

functioning

in

veterans

of

Operations

EnduringFreedom

and

Iraqi

Freedom.

J

Nerv

Mental

Dis

2009;197(10):74853.[3] PolusnyMA,Kehle SM,NelsonNW,Erbes CR, Arbisi PA, Thuras P. Longitudinal

effects of mild traumatic brain injury and posttraumatic stress disorder

Table 2

Communication

techniques

to

promote

culturally

sensitive

interactions

among

health

care

providers

and

veterans.

Cultural domain Communication techniques Questions Examples from semi-structured interviews

Intrapersonal

Eliciting

challenges

What

kind

of

feelings

have

you

had

about

your

deployment

experience?

How have you been feeling about yourself since returning

home?

Feeling

anxious

when

experiencing

something

that

evokes deployment

Lack of confidence

Feeling aimless

Fostering growth What would help you come to terms with your deployment

experiences?

Willingness to try mental health treatment

Establishing a regular exercise routine

Finding creative activities

Professional/educational

Eliciting challenges Can you tell me about some of the workplace challenges you

have faced recently?

Job/academic dissatisfaction

Diminished importance of work/school

Feeling useless in civilian life

Fostering growth As a servicemember, you already havemany skills prospective

employers may be interested in. Can you tell me some of the

skills

you

cultivated

in

the

military?

Applying military skills to civilian workplaces

Recognizing opportunity for educational

achievement

Interpersonal

Eliciting challenges Who are you spending time with after returning home?

How have you felt that your friends or family relationships

have

changed

while

you

were

deployed?

Spending time alone, e.g., social isolation

Close personal relationships no longer seem close

Fostering growth Can you identify one person whom you can talk to about your

deployment experiences?

Are you a member of a social or religious group?

Maintaining meaningful social connections

Participating in group, religious, and/or spiritual

activities



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