Iranian Journal of War and Public Health

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Volume 14, Issue 3 (2022)                   Iran J War Public Health 2022, 14(3): 263-269 | Back to browse issues page

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Oudi D, Nakhaei M, Mohtasham S, Esmaeili A, Vagharseyydein S. Development of Life Meaning as a Coping Strategy among Spouses of Post-Traumatic Stress Disorder War Veterans: A Qualitative Study. Iran J War Public Health 2022; 14 (3) : 3
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1- Department of Nursing, Faculty of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran
2- Department of Psychiatry, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
3- “Department of Psychiatry, School of Medicine” and “Medical Toxicology and Drug Abuse Research Center”, Birjand University of Medical Sciences, Birjand, Iran
* Corresponding Author Address: Birjand University of Medical Sciences, Ghaffari Street, Birjand, Iran (waghars@bums.ac.ir)
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Introduction
Post-traumatic stress disorder (PTSD) is a mental disorder that may occur in people who have experienced or encountered a very serious or life-threatening accident. The prevalence of this mental disorder is reported to be 7-20% in the general population [1, 2] and about %7 -17 in United States war veterans [3]. PTSD Prevalence in Iranian war veterans seems to be higher than the global statistics [4] and is estimated at 27.8%[5].
Different studies on PTSD complications in veterans’ families indicate multiple effects of this disorder on the family such as adverse effects on the spouse’s adaptation skills [6, 7], spousal abuse [7, 8], aggression and violence against the spouse [6, 7, 9], increased responsibility and mental distress on family members [7, 10], spouse’s loneliness and isolation [11], adverse effects on spouse's mental health [12, 13] and depression and anxiety of veterans' spouse [14]. Veterans with this disorder impose psychological stress on their spouses [15], while many of their spouses don’t receive sufficient social and family support [16]. Veterans’ wife suffers from loneliness, lack of supportive resources, social isolation, and mental support too [17, 18] in traditional and religious cultures, spouse and relatives are responsible for caring for the veteran. Facing the difficulties of living with a veteran with PTSD as well as the difficulties of caring for him can disturb and change the family balance and dynamism [19].
That is, facing the challenges caused by a veteran who suffers from PTSD, forces relatives to accept new personal and context-based roles and adaptation mechanisms [20, 21]. To date, most studies focused on veterans themselves and there is a clear lack of studies about veterans' relatives' and families' issues and challenges [16, 21]. And lack of knowledge regarding veterans’ spouses' coping strategies in confronting the challenges of living with veterans who suffer from PTSD is seen.
Since the challenges and complications of veterans' spouses stem from cultural, religious, economic, and many other conditions, it needs to be understood the viewpoints and experiences of veterans' spouses in each culture. In this research, researchers decided to capture veterans’ spouse experiences to better explain their coping strategies in facing their life challenges by qualitative approach [22].
This paper aimed to explore and shape the knowledge of veterans’ spouses' coping strategies in all aspects of their life in our cultural context and it can help to better manage coping strategies used by them.

Participants and Methods
This research was conducted to explain PTSD veterans' spouses coping strategies in confronting complications and challenges of living with a veteran who suffers from PTSD; the qualitative research method incorporates content analysis, which seems to be a suitable design when exploring new domains to be investigated in an explorative style or if the domain should be explored as a new approach [23], was selected. Participants were selected from women who were able to share their experiences with the researcher, lived as the spouse of PTSD veterans, had a formal veteran record at the Martyr Foundation and Veterans Affairs, and were being treated as post-trauma stress disorder in a purposeful sampling method. At first, PTSD veterans' spouses who were living with veterans were selected and in continuation, other rich informants’ participants were chosen based on our research needs. The research participants were 15 spouses of veterans with PTSD who had a formal veteran record. Participants ranged from 37 to 70 years old and were living under a roof with PTSD veterans. The majority of participants were housekeepers. In most cases, they have to do some informal jobs out of the home to help the family's economy. Interviews were conducted in medical or service centers affiliated with the Veterans Foundation of Mashhad and Birjand, and all participants participated in this study with informed consent and were assured that they could leave the study without consequences or questioning at any point. The sample size was determined by saturation and the research team concluded data were repeating and new codes were not found or existing codes were not extended.
The study was approved by the Ethics Committee of Birjand University of Medical Sciences. At the beginning of the interviews, the purpose of the study was explained to each of the participants. Participants’ consent to record their voices during the interviews was obtained. They were assured that they could leave the study at any point and that their identities would be kept confidential by researchers. Data was collected using semi-structured and in-depth interviews. Data collection was conducted between December 2020 and February 2022. The time and place of the interviews were selected upon agreement with the participants. Interviews were recorded by digital audio recorder. The interview was initiated with an open-ended primary questions such as, “Please describe your experiences of living with a veteran?” and “Please describe your experience of coping with problems of living with a veteran.” It was continued with more probing questions, such as “Would you please explain more?” Interviews lasted approximately 60-90 minutes. All interviews were transcribed verbatim by the researcher and continued until saturation was reached and no new information emerged. Lincoln and Guba’s criteria were used to ensuring the validity and reliability of the data [23] To ensure credibility, the researcher had a long-term engagement (approximately 13 months), from December 2020 to February 2022, with the subject, information, and participants. Member checks and expert checks were also used after coding. After the data was analyzed, the appeared categories and subcategories were shared with the participants. For credibility, the transcribed interviews were returned to the participants and they confirmed an overall comprehension of the data. The codes and categories were monitored and confirmed by a research team, which had rich experience in qualitative research. The researchers considered the maximum variation in sampling for acquiring proper data.
Data were analyzed using Graneheim’s content analysis method. The recorded interviews were listened to several times to obtain an in-depth and overall understanding, then they were transcribed verbatim. The meaning units included words, sentences, or paragraphs, and were abstracted and labeled with a code. The numerous codes were compared and categorized based on differences and similarities in sense. Similar codes were sorted into subcategories and subsequently, similar subcategories were combined to create categories based on coping strategies. Data analysis was conducted using the MAXQDA 2020 software.


Findings                        
Fifteen spouses of war veterans with PTSD participated in this study. Participants ranged in age from 37 to 70 years. The literacy level of most of the participants was high school education to a general diploma. All participants were spouses of PTSD veterans with formal records in the martyr and veterans foundation and were living with the veteran under a roof. Their marital length with veteran average was 31 years.
At first, all interviews were listened to several times, then transcribed verbatim and all the meaning units were labeled into primary codes. 1481 primary codes were extracted from all interviews. Primary codes were compared regarding differences and similarities and 40 primary subcategories were produced. In an inductive process, 8 subcategories were extracted from secondary codes, and so 4 categories and one theme were obtained.

Table 1) Coping strategies of spouses of war veterans with PTSD



Meaning of life development
The theme obtained in this study was the meaning of life development. It was extracted from veterans who suffer from PTSD spouses' experiences. Veterans who suffer from PTSD spouses use three coping strategies (categories) in their lives; developing a value-based approach, altruistic family preservation, and beyond-defined gender roles. All these strategies used by them can be interpreted as the meaning of life development (theme).
-Developing a value-based approach
Spouses of veterans mentioned grief and lack of motivation, hope, comfort, and happiness as their most important problems in life. One of the strategies used by spouses to manage and cope with these difficulties was developing a value-based approach. This category includes bolding spiritual values of life and Value rich care.
Bolding spiritual values, and directing the definition of life from appearance towards the depth and spiritual concepts helps veterans’ wives to expand the depth and extent of their attitude in life and by this, they can compensate for economic defects through spiritual values and preserve their motivation to advance life and confronting difficulties.
Participant (P2) as a spouse of a veteran said:
"I deal with old clothes, lowered my expectations, and adapt to what I do not have … life could not be sweet by money and clothes. If you learn to deal and cope with defects and difficulties you are happy and you can taste the sweetness of your life”
Another participant (P5) described her attitude on life as:
"Life can be dusty, but the heart should be happy. It means happiness”
Another strategy used by many spouses of veterans was developing their religious approach. By religious approach, they could better cope with complications and difficulties in their life. In other words, direction toward religious reliance and values helped them more efficiently confront life difficulties, and by these, the spouses of veterans who suffer from PTSD find a new and endless source of power.
One of the participants (P10) veterans' spouses stated:
"Once I wished to have everything, but now I don’t care if they give me the whole city, I don’t value them anymore, because I abandoned the world’s wealth and I do not love it anymore. May God gives me life so that I can raise my children". Then, I don’t have any wishes and I only want to make these children fortunate. I have no other hope and desire for myself, I wish to go to Mecca, Karbala, of course, God willing."
Another wife of veterans (P3) stated:
 “First I endured for the sake of God, and then for my children… in hope of being happy in hereafter world. Because I make a covenant with God and I endure for God's sake.
About religious reliance one of the veterans’ spouses (P2) explained:
“I only try for Allah, and god gives me my reward and my reliance is on Allah and Imams… and I surrendered myself to god”
-Altruistic family preservation
Another strategy used by spouses of veterans in the face of the disintegration of the structure and loss of family cohesion was to change the attitude towards sacrifice in family life to preserve cohesion and family stability. They had changed their attitude to self-sacrifice to preserve the cohesion and structure of the family to prevent the family structure and cohesion disintegration.
One of the spouses (P18) said in this regard:
"In case of any arguments, I humiliate myself, I talk and blame myself, and say I was guilty, I was a sinner, and I somehow make it up to him and I don’t let him get resented."
Since beating and physical violence are common during a veteran's aggression, many veterans' spouses even forgive the veteran in the face of physical violence and ignore their rights.
Participant no (P8) explained:
"I tell myself that he is not in control, he doesn’t want it and doesn’t like to hit me, and he didn’t use to hit me before." I don’t complain why for example he beat me today. I don’t moan about why he treated me this way. Well, it is not his fault, he is a mentally ill veteran patient.”
Spouses of veterans endure and continue family life for the sake of their children and veterans, despite many hardships and despair in their future, and although they have no hope for their future and ignore their priorities, they continue to live for the sake of other members of the family and make attempt for its cohesion and advancement.
One of the veteran's spouses (P2) explained:
"I’m very satisfied with my sons and they are gold, helping a lot to cope with the sorrows and I hope in my children and I have to raise them to high levels and I will stay to do so"
Having stayed in life because of his veteran another participant (P6) said:
"But if I say I love my life and I stay with this man, it's only for his own sake, and not for anything else, I stayed for his own sake, when we got engaged, my family told me he is not suitable for you and wanted to separate us, but I stayed with him because I loved him."
Veterans' spouses worked hard for the physical well-being of family members so that in some cases these efforts were beyond their ability and capacity, and the cost of this effort for the physical well-being of family members was ignoring their health. They sacrificed themselves for the health and well-being of family members.
A veteran’s spouse (P5) explained about sacrificing her health for the well-being and health of her family members:
“I take tablets for my nerves to be able to take care of him, but I still get so nervous and get agitated which hurts my heart, they talk a lot. I explain things to my husband two or three times and my mother talks a lot, for example, should I eat bread or have tea?" But I control myself, I wait for God's reward, God may have a reward for it, and may God grant me patience to be able to take care of my mother and husband. He gets so mad, and early days, when I was young, he kicked me a lot. Once he kicked my waist such that it hurts when I eat and drink. Now I’m suffering from a hernia, they say I must operate, but I didn’t do it.”
Another veteran's spouse (P10) said in this regard:
"I’m exhausted, a doctor told me to visit a physiotherapist, and my legs are crooked and I need surgery, but if I have surgery, who will take care of my husband? I always believe that he needs to get better, and I’m not important."
-Beyond defined gender roles
Since veterans suffer from PTSD had lost much of their physical, mental, familial, and social abilities due to the disorder and are unable to perform their conventional tasks in life and society, their spouses compensate instead of their husbands and take on the roles that the veteran is unable to do, in another word they go beyond their defined gender roles to accept conventional male roles.
Many of the roles conventionally assigned to men in our society are known as masculine roles in our culture and are usually physically heavier. In the cultural context of our society, men are expected to accept these roles in the family, while in the families of veterans due to the need and inability of veterans who suffer from PTSD, most of their spouses take on these roles with the development of their normal gender roles.
The spouse of one of the veterans (P8) said:
"When you have a careless husband who is always so sick, and when a woman wants to support a six-member family and overcome the hardships of life, then she should be a man. When my child got married I was financially weak and sir (veteran) didn’t notice any financial problems. Until recently, I was paying my child’s carpet installments. Instead of his dad, I bought gold for my bride and bought clothes and set the wedding table, and I didn’t let any shortages happen."
What is certain is that developing gender roles changes the characteristics and aspects of conventional femininity in veterans' spouse, because performing roles attributed to men in our society and its cultural context largely demands the acquisition of characteristics attributed to men and that veterans' spouse is forced to acquire these characteristics and distance her from conventional feminine roles.
In this regard, the spouse of one of the veterans (P13) mentioned:
"I tell you as a brother, that is, I came out of being a woman, and it means I became a man and I’m not a woman anymore and I’m no longer sensitive. They say a woman is like a flower, but I’m not. I have no feminine feelings and others say I’m a woman, I say I’m not a woman, and I got out of my womanhood when I raised 3 children with difficulty. I worked so much and suffered so much that I do not feel feminine to be sensitive. I did a harder job than I could and got out of being a woman that should be elegant, and I became a different person. I realize that it's not good."
The growth and expansion of conventional gender roles, followed by the acceptance and performance of conventional male roles, willingly or unwillingly, diminishes feminine attraction and elegance, so that spouses of veterans showed less interest and attention to conventional female elegance. One of the veterans' spouses (P11) said:
"I have completely been changed and I have become a special person who only prays and recites the Qur'an and is not interested in feminine elegance and passions. I have a condition that I may not go to a hairdresser once every year and my hair has turned white, my friend says dye your hair, but I am not in the mood to do so."
-Mutual beneficial care
Another coping strategy to manage the problems of life was the value-based attitude of the veterans' spouses towards taking constant care of the veteran. This strategy helped the veterans' spouses to cope problems of permanent and difficult care of the veteran. According to the participants, veterans had high spiritual value and high status in society, and sight of God. By this approach and viewpoint caring for their spouses was respectful and valuable to them.
One of the veterans' spouses (P10) said about the value of the veteran’s status:
"They went and sacrificed their lives for us so that we could breathe comfortably now so that strangers don’t intrude houses and bully our family, they left for the sake of us, they also wanted their health and wanted to be happy,... If they had not gone, we would not be here now.
Another participant (P8) described how she felt about caring for the veteran:
"I don’t upset at all by working for him, I’m even proud of working for him to take him to the bathroom, cook for him, and provide breakfast for him."
Many PTSD veteran’s spouses tried to change their attitude from being a loser to being a winner in their life as a coping strategy, they tried to develop their vision of themselves from a loser caring machine to a winner person by learning life skills, being grateful for self-health and enhancing their self-esteem. Veterans' spouses had achieved these advantages in caring for a worthy person and enduring the hardships of caring for a socially valuable member, and in the hope of god’s forgiveness as a result.
One of the spouses (P5) explains: “these men (veterans) went to war for defending their soil and now suffer PTSD as a veteran. They have pain and suffer from their disorder… caring for them is so difficult and as a spouse, you must learn how to be patient and if he explodes you must learn to be patient as you try to calm your husband too. You must learn how to live with defects and feel happy too. Living in a straight line without challenges is not artful !…”

Discussion
The present study aims at discovering the coping strategies of battle-scarred veterans with PTSD in the face of life difficulties. In the present study, these coping strategies and mechanisms were categorized into one theme of the meaning of life development and four categories, namely, the development of a value-based approach, Altruistic family preservation, beyond defined gender roles, and mutual beneficial care.
Regarding the changes in the married life of the veterans with PTSD, the spouses found that the veterans were not able to perform their roles and responsibilities as before to progress and manage life with the desired economic quality, and is far from their expected welfare and facilities. This event and the lack of hope to achieve the facilities, financial and economic goals in life led to the application of a strategy to develop a value-based approach to life in the spouses of veterans with PTSD. This coping strategy led to the development and greater focus of their spouses on spiritual issues and values ​​in the face of these deficiencies. This change in attention and development of an approach to spiritual values leads to easier coping and tolerance of life difficulties and more effective coping with economic deficiencies.in other words, responsibility, pressure, and changes in the marital life of the spouses develop their perspective and approach to life and redefine life's meaning and concept. These changes in approach and attention to value-based concepts occur to preserve peace in the family, prevent conflicts, have a better life and solve its problems.
Another strategy for the spouses of veterans to cope with the problems and difficulties of complete and full-time care without the hope of improvement in the veteran was creating a value-based attitude to endure these difficulties and problems. Previous research on coping methods of spouses of people with mental health problems also provided a value-based and spiritual attitude to the problems and suffering caused by it. As the spouse or relatives of the person with incurable and chronic mental problems extended their attitude about trying and performing various roles in caring for the sick person to spiritual and value-based care. Value-based care strategies in difficulties caused by caring for a mentally ill member were considered a source of strength and motivation in advancing life and feeling calm in the face of the challenges and difficulties of caring for a sick family member [24].
Developing a value-based approach was observed in the dimensions of social relations, the definition of well-being, and lifestyle. Developing an approach to life and changing lifestyles was one of the coping strategies of the spouses when dealing with new life changes and problems, and the results in previous studies were consistent with these findings [16, 25].
Regarding the development of a value-based approach to life, this is a coping strategy to pay more attention to and emphasize the religious and spiritual approach to life. Using this strategy, the spouses of veterans have interpreted and redefined life with a new and expanded encyclopedia of values, and by using such interpretation and developed view of the surrounding world, they will gain a more constructive feeling and perception of their life, and as a result, they will have a more useful and effective encounter and coping to life's challenges [25, 26].
Suffering with PTSD causes a decline in the veteran's functions in various familial and social aspects, and this decline in function, especially in the familial and individual context puts double pressure on the veteran’s spouse and demands his spouse's more effort. In order to compensate for these shortcomings and deficiencies, as a result, they are forced to accept roles that are beyond their power and sacrifice their rights to cope with the problems. The roles and responsibilities of individuals in these families are not divided fairly and due to the reduction of veterans’ functions, their spouses are forced to accept responsibilities and duties heavier than their ability which reduces the time and quality of self-care making the veterans’ spouse give up her rights and do self-sacrifice, especially in the areas of personal health, to preserve the family structure and cohesion [25, 26].
Veterans' spouses inevitably take responsibility for solving and managing most family problems alone and with personal responsibility [21], and since accepting and undertaking most of the responsibilities and managing family problems requires the sacrifice of individual rights, it can be stated that they use self-sacrifice as a strategy to deal with life's problems and try not to involve other members in problems and responsibilities, and use self-sacrifice as a coping strategy to advance life and preserve family structure and cohesion [27].
Some spouses of veterans with PTSD mandatory sacrifice their mental and physical health to preserve and improve the health of other family members and preserve and improve the health of family members at the cost of losing their health [28].
Changing attitudes towards their role and consequently changing feminine characteristics and ignoring conventional feminine elegance was another strategy of veterans' spouses. This is such that spouses of veterans believe that their role as women has changed and they have to inevitably accept new and unwanted roles to care for the veteran and advance life. Also in the face of financial challenges caused by the veteran’s inability to earn sufficient income, they have been forced to have jobs that are outside of their conventional feminine role which led them to accept conventional male roles and as a result, get distant and consequently disregard conventional feminine characteristics [22, 29].
One of the unique results reached in this study was care benefits for wives not only for veterans as a care receivers. in our culture by enduring in veterans' care Veteran spouses gained some benefits like enhanced self-esteem and life skills. They were in hope of forgiveness by god too. In available search motors, we couldn’t see similar findings and this may relate to our religious or war special values that are unique for our context.

Conclusion
Spouses of veterans with PTSD face many challenges and problems, including economic problems, problems caused by the veteran's illness and its challenges, the veterans’ inability to perform their roles and responsibilities in the family, etc. On the one hand, facing the above-mentioned issues, and on the other, the lack of financial and spiritual support, both governmental and non-governmental, made the life path of the veterans’ spouses very difficult. In dealing with these situations, they used various coping strategies to progress and preserve the family. The coping strategies used by them were often profound, meaningful, and belief-oriented, so that in the face of life throughout their challenges, spouses were forced to expand and develop meaning and definition of life. developing the meaning and concept of life leads to the formation of a new and developed encyclopedia of defining the concepts of life and enables them to gain a more constructive and valuable view and understanding of the meaning of life and therefore, have a more constructive and effective encounter with the challenges and ups and downs of life.

Acknowledgments: The researchers of the present study deem it necessary to appreciate all the spouses of veterans with PTSD who helped us in this study. This study is extracted from a doctorate dissertation from Birjand University of Medical Sciences.
Ethical Permissions: The recent study was approved by the ethics committee of Birjand University of Medical Sciences with code No. IR.BUMS.REC.1399.453.
Conflicts of Interests: This study was a part of a larger PhD project. The authors declared no conflict of interest.
Authors’ Contributions: Oudi D (First Author), Introduction Writer (20%); Nakhaei M (Second Author), Methodologist (20%); Mohtasham S (Third Author), Main Researcher (20%); Esmaeili A (Forth Author), Assistant Researcher (20%); Vagharseyydein SA (Fifth Author), Discussion Writer (20%)
Funding/Support: There was no any sponsor or financial support in this study
Keywords:

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