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«THE INFLUENCE OF CONTEXTUAL FACTORS ON COMMUNITY REINTEGRATION AMONG SERVICE MEMBERS INJURED IN THE GLOBAL WAR ON TERRORISM A Dissertation Presented ...»

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THE INFLUENCE OF CONTEXTUAL FACTORS ON COMMUNITY

REINTEGRATION AMONG SERVICE MEMBERS INJURED IN THE GLOBAL

WAR ON TERRORISM

A Dissertation

Presented to

the Graduate School of

Clemson University

In Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy

Parks, Recreation, and Tourism Management

by

Brent Lindsay Hawkins

August 2013

Accepted by:

Dr. Francis A. McGuire, Committee Chair Dr. Alison L. Cory Dr. Sandra M. Linder Dr. Thomas W. Britt ABSTRACT Community reintegration among military service members with physical and psychological injuries sustained during combat has been an emerging issue since the beginning of the Global War on Terror (GWOT) in 2001. Injured service members from the GWOT, including Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn, are much more likely to survive their injuries when compared to previous wars such as the Vietnam War and World War II (Holcomb, Stansbury, Champion, Wade, & Bellamy, 2006). Therefore, many more injured service members are receiving physical rehabilitation and mental health services to assist them in transitioning back into their homes and communities. Recent studies have indicated that injured service members are at risk of poor community reintegration (Resnik & Allen, 2007; Resnik, Plow, & Jette, 2009). However, these studies have neglected to account for personal and environmental factors (e.g., contextual factors) that influence community reintegration. These contextual factors have the potential to greatly affect an injured service members ability to reintegrate (Resnik et al., 2012). Therefore, the purpose of this mixed methods study was to identify and explain the influence of contextual factors on community reintegration among service members who have sustained physical and/or psychological injuries while serving in the GWOT.

ii DEDICATION This dissertation is dedicated to the men and women who served in the United States military and sacrificed their bodies and minds for their comrades and our country.

We, as civilians, therapists, and service providers must return the favor by helping them heal from the physical and mental wounds of war. This dissertation was completed in appreciation of our freedoms as a result of their sacrifice.

ii

–  –  –

First, I thank the service members who participated in the study and freely shared their time and experiences. The process of better understanding how to help injured service members began with those who participated in this study.

Next, I thank my committee members Dr. Fran McGuire, Dr. Lynne Cory, Dr.

Sandy Linder, and Dr. Tom Britt. Their insight, guidance, and encouragement throughout the dissertation process challenged and motivated me until the completion. I also thank my fellow graduate students who assisted with this dissertation by listening to the many presentations associated with the project, helping with problem solving in various stages of the dissertation, transcribing interviews, analyzing interviews, sharing the humor in academics and research, and sharing the day-to-day struggles and triumphs as a graduate student.

Most importantly, I thank my wife, Carmen, for her love, patience, emotional support, and financial support throughout this process. The countless nights and weekends I spent working on my dissertation and degree, enduring the offbeat academic language and humor shared by our friends and my fellow graduate students, and the many other challenges of being the wife of a PhD student are recognized and greatly appreciated. I also thank my Mom and Dad for always believing in me even when I did not. I will never be able to repay everything you have done for me.

–  –  –

TITLE PAGE

Abstract

DEDICATION

ACKNOWLEDGMENTS

LIST OF TABLES

LIST OF FIGURES

CHAPTERS I. INTRODUCTION

Background

Problem Statement

Research Questions

Conceptual Framework

Theoretical Framework

Relationship between ICF and SCT

Conclusion

List of Definitions and Abbreviations

II. LITERATURE REVIEW

Injury among Injured Service Members

Rehabilitation Services

Community Reintegration

Influence of Environmental Factors

Influence of Personal Factors

Summary

III. METHOD

Framework

Participants

Quantitative Methods

–  –  –

Data Mixing for Qualitative Methods

Qualitative Methods

Final Data Mixing

IV. RESULTS

Quantitative Data Cleaning

Quantitative Results

Data Mixing for Qualitative Sampling

Qualitative Results

Results of Final Data Mixing

V. DISCUSSION

Summary of Primary Findings

Summary of Secondary Findings

Connection to Frameworks

Connection to Previous Studies

Practical Implications

Future Research





Study Limitations

APPENDICES

A: Community Reintegration of Injured Service Members subscale sample items

B: Craig Hospital Inventory of Environmental Factors items

C: Interview Protocol

D: Summary of Organizations/Individuals Contacted for Participant Recruitment

REFERENCES

–  –  –

1.1 Sample of the Domains and Components in ICF’s Environmental Taxonomy

2.1 Casualty Summary

3.1 New General Self-Efficacy Scale Items

4.1 Sample Descriptive Statistics

4.2 Correlations between Contextual Variables and Community Reintegration

4.3 Group Differences on General Background Information

4.4 Group Differences on Injury and Related History

4.5 Group Differences on Community Reintegration and Contextual Variables

4.6 Interview Participant Information

4.7 Prevalence of Themes across Interview Participants

4.8 Matrix for Comparison of Overarching Quantitative and Qualitative Results

4.9 Matrix for Comparison of Results between Reintegration Clusters.......... 109

4.10 Comparison of Relative Importance according to Quantitative and Qualitative Results

–  –  –

1.1 The International Classification of Functioning, Disability and Health Interaction Model

1.2 Social Cognitive Theory Model

1.3 Graphical Relationship between ICF and SCT

3.1 Sequential Explanatory Design Logic Model and Procedures

4.1 Clusters based on Reintegration Scores

4.2 Interview Participants and Cluster Affiliation

–  –  –

Community reintegration among injured military service members who have returned to the United States with physical and psychological injuries sustained during combat has been an emerging issue since the beginning of the Global War on Terror (GWOT) in 2001 (Garcia, 2010; “Improving Care,” 2009; Resnik & Allen, 2007; Trudel, Nidiffer, & Barth, 2007). Service members injured in the GWOT, such as Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND), are much more likely to survive their injuries when compared to previous wars such as Vietnam War and World War II (Department of Defense, 2012; Gawande, 2004;

Holcomb et al., 2006). Therefore, many more injured service members are receiving physical rehabilitation and mental health services to assist them in transitioning back into their homes and communities, also referred to as community reintegration. Recent studies have conceptualized and measured community reintegration among injured service members (Resnik, Gray, & Borgia, 2011; Resnik & Allen, 2007; Resnik & Plow, 2009; Resnik et al., 2009); however, these studies have not accounted for the personal and environmental factors (i.e., contextual factors) that influence the injured service members’ ability to live active and engaged lifestyles in their homes and community.

This study proposed to address this limitation by striving to better understand how contextual factors influence community reintegration among service members injured in the GWOT. The next sections in this introduction will provide a rationale for the study including a description of the (a) background of the research, (b) problem statement, (c) research questions, and (d) conceptual and theoretical frameworks driving the study.

Background Casualties have been vast during the most recent United States combat missions, including OEF, OIF, and OND. Reports from the Department of Defense (2013) indicate that 6,716 military deaths in the GWOT (2,241 in OEF, 4,409 in OIF, and 66 in OND).

The largest numbers of deaths occur among males, under the age of 30, serving in the Army, and in active duty. Not surprisingly, the same demographic profile is true for service members wounded in action. However, the total numbers of service members who have been wounded are much higher than those who have been killed including 18,950 in OEF, 31,927 in OIF, and 295 in OND (Department of Defense, 2013).

Some of the most traumatic injuries sustained during active duty include brain injury (BI), major limb loss, severe orthopedic injuries, spinal cord injury (SCI), emotional and psychological adjustment problems (e.g., post-traumatic stress disorder (PTSD) and depression), and polytrauma (Fitzpatrick & Pasquina, 2010; Hoge, Castro, Messer, & McGurk, 2004; Lapierre, Schwegler, & LaBauve, 2007; Sandberg, Bush, & Martin, 2009; “Wounded Warriors,” 2009). These traumatic physical and psychological injuries often lead to complications with psychosocial adjustment once injured service members attempt to return back into home and society as a civilian.

To help with the transition from being in the military to being a civilian with a disability, the Department of Veterans Affairs (VA) and other organizations have established physical and mental health rehabilitation services for injured service members. These services are designed to assist them with increasing their independent living and adaptive skills necessary for successful transition back into military service (if possible) or return to a civilian lifestyle. The adjustment process that accompanies these injuries present unique challenges for the injured service members and rehabilitation personnel and as they progress through various types of treatment services available, such as acute care, physical and cognitive rehabilitation, mental health services, transitional programs, and community programs (Doyle & Peterson, 2005; Fitzpatrick & Pasquina, 2010; Resnik & Allen, 2007). One therapeutic service available to many injured service members in rehabilitation and community-based programs is recreational therapy. Many recreation and recreational therapy programs are designed to assist injured service members with overcoming challenges related to physical and psychological injury to regain community engagement and an active and healthy lifestyle after injury. (Hawkins, Cory, & Crowe, 2011; Lundberg, Bennett, & Smith, 2011; US Department of Veterans Affairs, 2011; Van Puymbroeck & Lundberg, 2011; Wilder, Craig, Sable, & Gravink, 2011).

For many service members whether injured or not, the transition from being in the military to being a civilian proves to be difficult. This transition is especially difficult for injured service members. An individual with significant injuries has to adjust to his/her impairments as well as his/her home, community, and other social environments. These

injuries often result in unforeseen challenges and lifestyle changes as demonstrated by:

(a) difficulties with family life (Bocarro & Sable, 2003); (b) problems with transportation and accessibility (Wehman et al., 1999); (c) inability to return to work (Corrigan et al., 2007); and (d) decreased involvement in physical activity, sport, recreation, and leisure activities (Levins, Redenbach, & Dyck, 2004; Tasiemski, Bergström, Savic, & Gardner, 2000; Tasiemski, Kennedy, & Gardner, 2006). These life changes are likely influenced by a number of ecological factors surrounding the service member, such as the quality and amount of social support available, political and cultural support systems, accessibility of physical environments, as well as personal influences such as motivation, confidence, and willingness to adjust to a new lifestyle (Bandura, 2001; World Health Organization, 2001a). Therefore, it is necessary to understand the unique contexts in which the transition from military service to civilian life takes place.

Problem Statement Community reintegration after injury during military service can be challenging for the thousands of service members who have been injured during the GWOT.

Although research studies have reported the risk of poor reintegration after military service, little is known about the context in which injured service members make this transition. This dissertation will address this gap in the literature and better understand the contextual influences, both personal and environmental, related to participating in home and community activities (i.e., community reintegration) among service members who were injured in the GWOT.

Research Questions The study will answer the following primary research questions to better

understand the context of community reintegration after injury:

Mixed Methods Question: To what extent do contextual factors (e.g., personal and environmental) influence community reintegration of injured service members?

Quantitative Question: Which contextual factors are significantly related to community reintegration among injured service members?

Qualitative Question: How does the influence of contextual factors differ among injured service members with different levels of community reintegration?



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