Authored by James Abel
Abstract
Military deployment come with a host of psychological challenges that
affect soldiers’ quality of life and performance in future military
operations. Posttraumatic stress disorder and depression are conditions
commonly associated with combat deployment among military veterans.
Previous studies indicate that, a substantial number of military
returnees from combat zones experience psychological distress,
manifesting in
form of anxiety and depression. However, these studies have provided
little empirical evidence on the comorbidity in a single population of
study.
In Nigeria, for instance, there is still unfilled gap as to whether
military personnel with combat-related PTSD would also experience
depressive
symptoms. In addition, little is known about the role of unit social
support in the relationships between combat exposure, self-efficacy and
the two
dimensions of psychological distress. This study therefore investigated
the role of combat exposure, self-efficacy on both anxiety and
depression
components of distress, and the moderating role of unit social support
in the relationships between these variables among Nigerian military
returnees from Boko-Haram insurgency. A cross-sectional survey method
was adopted. Standardized questionnaires were used to collect data from
605 military returnees across six military units in three northern
states. Pearson correlation and hierarchical multiple regression were
used to
analyzed the carefully retrieved data. Results revealed a significant
negative relationship between combat exposure (r=.089;<.05) and
self-efficacy
(r= -.019; <.05) on anxiety. Unit social support showed a significant
negative relationship with anxiety (r= -.120; .01) and depression (r=
-.115;
>.01). Results also indicated that combat exposure independently
predicted anxiety (β= .06, t = 1.54, p <.05) and depression (β= .58, t
= 1.54, p <.05),
while self-efficacy did not predict neither anxiety (β= .01, t = -24, p
>.05) nor depression (β= .09, t -24, p >.05). Further results
indicated a significant
interaction of unit social support and combat exposure on anxiety (ΔR2 =
.021, β,.08, t, .47; p >.05) and self-efficacy (ΔR2 = .021, β,-.41,
t, -2.00; p
>.01) on anxiety component of psychological distress. The influence
of self-efficacy on anxiety was low at high level of unit social support
compared
to when unit social support was low. This shows that providing immediate
support during deployment to veterans could attenuate the negative
effects of combat and self-efficacy on anxiety. Therefore, Nigerian
military authority, colleagues and friends of the personnel should
always provide
sufficient support particularly during combat to boost solders’
confidence and reduce the deleterious effects of these risk factors on
anxiety level of
their personnel in order to promote effective performance.
Globally speaking, military personnel returning from combat
operations are faced with several psychosocial challenges capable
of affecting their personal functioning and productivity. In recent
times, however, empirical reports have shown astronomical rise
in psychological consequences of war among military veterans
who return from combat operations [1-3]. According to Mirowsky
and Ross, psychological distress is a state of emotional suffering
characterized by symptoms of anxiety and depression. Upon return
from combat engagement, the traumatic events experienced at
combat may make many military veterans to become severely
distressed due their impact on mood and healthy psychological
functioning. For example, having experiences such as witnessing
death, being ambushed, exposure to decomposing bodies and
hostile fire may continue to intrude consciousness and be reexperienced
many years after a soldier has returned from war the
zone. This continuous intrusion could propel guilt, increase anxiety,
affect postwar social life, promote suicidal thoughts and ultimately
slip a veteran into unavoidable anxiety and depression problem
[4].In addition, many of the veterans may lose interest in activities
that were once pleasurable, experience loss of appetite, have
problems concentrating, remembering details or making decisions,
experience relationship difficulties and perform poorly in workplace.
Unfortunately, such symptoms are antithetical to the warrior
spirit and inconsistent with the behaviors and persona so highly
valued in the military environment. Therefore, those who suffer
may be reluctant to admit it or seek help, and may rather suffer
in silence, numb the pain and ultimately suffer from unimaginable
psychological distress.
Research has shown that between 13 to 32% of combat veterans
are likely to experience psychological problems after homecoming
[5,6]. Particularly, studies among American and Chinese Dai J,
et al. [6] Cesur, Sabia & Tekin, South African [2] and Nigerian
[7,8] combatants have shown that many military returnees from
warzones suffer from posttraumatic stress disorder. In addition to
PTSD, studies have also pointed out that exposure to unpleasant
combat events can lead to symptoms of depression in military
veterans Hoge CW, et al. [9]; Seal, Metzier, Gima, Bertenthal, Maguen,
& Marmar. Findings from research exploring psychological distress
in operation Afghanistan and Iraqi freedom revealed that, out of
the 21.8% veterans who reported PTSD, 17.4% had a full diagnosis
of depression Seal, et al. Unfortunately, soldiers who receive this
diagnosis have been found to experience other problems, such as
lack of job satisfaction, sick leave, increased substance use, negative
work, marital conflict Galovski T and Lyons JA [10]; Vinakor, Pierce,
Lewandowski, Romp, Hobfoll & Galea, cynicism and aggressive
behaviours Meis LA, et al. [11], compromised immune system, risky
health behaviors, cardiac-related problems, sleep difficulties and
general burnout [1].
Notwithstanding these increased risks, research evidence has
shown that in the face of comparable stressors like war trauma, majority
of military and police personnel show impressive resilience
and are unaffected by trauma while a minority exhibit significantly
impaired functioning [12-14]. This suggests that people are not
homogenous in their responses to stress and traumatic stress, and
points to the direction that individual and social factors might be
influential in the development of psychopathology or resilience.
Thus, one important factor that emerged in literature on risk and
protective factors is the salience of perceived control and its ability
to influence psychological distress. Previous studies [14] have
consistently demonstrated that the belief that military personnel
have concerning their ability or general capacity to handle stressful
situations has a significant role in stressful outcome. Perception in
one’s ability to successfully execute a given task, has been found
to influence performance and mental health [15]. Bandura A [16]
defined self-efficacy as the “belief in one’s ability or capability to
organize and execute the courses of action required to produce
a given attainment”. According to Bandura A [16] an individual
thoughts and beliefs about a traumatic experience play a significant
role in influencing behaviour including mental functioning and
psychological adjustment to trauma. Military personnel with high
perception concerning personal capacity to manage the stress
generated by Boko-Haram encounter may mobilize the necessary
psychological resources that prevent distressing thoughts,
feelings and behaviours, making them less likely to experience
psychological strain. Conversely, those who show poor control
to the event and see themselves as possessing low abilities may
experience adverse mental effect including posttraumatic stress
disorder and depression. This notion is supported by Bandura,
wherein he asserted that people who display low self-efficacy
when confronted with trauma may become extremely anxious and
display unpleasant negative emotions that may lead to depression.
Interestingly, availability of a healthy and supportive social
network has been found to buffer the negative impact of trauma
on distress. Although social support has been widely studied and
linked with PTSD and to a lesser degree, depression, less research
attention has been given to military unit social support [17,18].
This refers to the instrumental and emotional assistance and
encouragement provided by military leaders and unit members to
veterans during deployment [19]. This could be in form of material
or emotional support that military leaders and colleagues provide
to a veteran during deployment. This support is very important
to restore tranquility after participating /exposure to hostilities
that are imminent of any combat environment. Thus, with high
availability of such support, military personnel who encounter
these events may have positive coping thoughts, develop more
confidence in withstanding the challenges and become less affected
by them. According to Schwarzer R and Knoll N [20] availability of
social support helps in building self-confidence and modification
of coping ability to trauma. This suggest that, with support, selfefficacy
may become an insignificant factor in distress. Thus, in
military population, high level of support from military units have
been shown to protect against the development of PTSD while lack
of it has been associated with higher symptoms [21].
Unit support is very important to psychological health because
it is the first form of support that military personnel need to have
from their military environment to restore tranquility. During
combat engagement, military personnel may need some financial,
emotional and informational support from their unit leaders and
colleagues. Perception that this support will be available may
reduce the negative impact of the experiences and low coping
abilities on the development of psychological problems. Having
a sense of social support in form of discussing one’s distressing
deployment experiences with others, including mental health
service providers and unit members can reduce the deleterious
effect of trauma on psychological health and promote healthy
adjustment of a combatant [22].
Examining unit social support became imperative considering
the perceived unavailability or inadequate support that most
Nigerian soldiers claimed was lacking during the war. This variable
has not received sufficient attention as majority of research have
focused exclusively on postdeployment social support. In foreign
military population, only Polusney MA, et al. [23] attempted to
examine the role of unit support in trauma, but like many others,
their research was limited to PTSD. Therefore, in Nigeria where
military personnel have had repeated encounters with the dreaded
Boko-Haram Insurgents with potentially traumatic experiences
(being shot at, witnessing human deaths, being ambushed, being
exposed to improvised explosive devices (IEDs), experiencing
severe injuries amongst others, examining the moderating role of
unit social support in preventing psychological distress became
necessary. The imperativeness of this is premised research findings
revealing that combatants who lack sufficient support and social
cohesion find it difficult to adjust even long after deployment
[22,24-28]. In addition to lack of domestic research on unit social
support, most of the documented studies in military population
have focused exclusively on the anxiety (PTSD) component of
distress [7,8]. Thus, understanding the role of combat exposure and
self-efficacy in both anxiety and depression is lacking particularly
in Nigerian setting.
Given the importance of unit social support in distress, and
the imminent deleterious effects of psychological distress to the
military and security of the populace, this paper examined: (1),
the relationship between unit social support, combat exposure
and psychological distress- anxiety and depression; (2),whether
combat exposure and self-efficacy would predict all the dimensions
of psychological distress (anxiety and depression); (3) whether
unit social support would moderate the relationship between
combat exposure, self-efficacy and two dimensions of psychological
distress in military returnees from Boko-Haram insurgency in the
North-east.
Design/ Participants
The study adopted a cross-sectional survey, utilizing ex-post
facto design to examine association among study variables that
were not actively manipulated. Participants represented a sample of the active duty military personnel who had returned from
the Boko-Haram operation in the north-east. Six hundred and
five (605) returnees were purposively recruited at six military
locations/ Barracks across three Northern states of Bauchi (33
Artillary Brigade, 211 Demo Battalion and Nigerian Army school
of Armour), Gombe (301 General support Artillery) and Plateau
states (3 Armour Division Garrison and 82 battalion). Demographic
information revealed that the age range was between 18-56.
Concerning participants’ religious affiliation, 445(73.5%) were
Christians, while 160(16.5%) were of Islamic religion. Regarding
marital status, a total of 490 (80.90%) were married,115(11.1%)
were single military personnel. Analysis on participants’ rank
revealed that 130(21.5%) were private, 160 (26.4%) Lance
corporal, 100 (16.5%) corporal, 117 (19.3%) sergeant, 56(9.2%)
staff sergeant while a total of 42 (6.9%) belong to the other ranks.
Demographics and contextual variables
Demographic variables measured in this study included age,
marital status, rank, religion, educational qualification, family
history of mental illness while contextual variables were number
of deployments and cumulative length of deployment. Combat
exposure. Combat exposure was measured using 7-item self-report
combat exposure scale Keane, Caddell, & Taylor. This a widely used
measure that assess combat exposure specifically among military
population. The scale was designed to measure all forms of combat
situations such as wars, peacekeeping operations and terrorism.
Items are rated on a 5-point frequency (1= no or never to 5= more
than twelve times a week). High scores indicates high combat
exposure. The scale has been widely used among military veterans
and found to be a sound psychometric measure with Cronbach
alpha of .80 reported Keane, Caddell, & Taylor. In Nigerian military
population, the scale has been widely used and established as a
good measure of combat exposure [3]. Unit social support. Unit
social support was assessed using a 12-item self-report instrument
developed by Vogt, Smith, King, King, (2012). This instrument
measures the amount of instrumental and emotional assistance
that military personnel receive from unit leaders and colleagues
during deployment and is scored using the 4-point Likert scale. High
scores (44.9) indicates high unit social support while scores below
the mean infers low support. The scale has demonstrated robust
psychometric properties in studies involving military population.
In this study, the established internal consistency was .94
Self-efficacy. A 30-item self-efficacy scale Maddox, Mercandante,
Prentice-Dunn, Jacobs and Rogers was adopted and used to assess
participants’ self-efficacy in the study. The instrument measures
peoples’ perception about their personal ability and capacity to deal
with stressful challenges. Items are scored on a 5-point Likert scale
and higher scores indicates high self-efficacy. In terms of utility and
psychometric properties, Ayodele found it a good measure of selfefficacy
in civilian and non-civilian population.
Psychological Distress. Psychological distress was assessed
using a 21-item Depression Anxiety Stress Scale (DASS). This has
been shown to be a valid and reliable measure of the dimensions of
depression, anxiety, and stress separately but also taps into a more
general dimension of psychological distress. Scores for depression,
anxiety and stress are calculated by summing the scores for the
relevant items and multiplying them by two. Items are rated on a
4-point scale showing how much each particular statement applies
to the individual. Each of the components is interpreted separately
using a cut-off mark ranging between 8-9 for anxiety, 10-13 for
depression, 15-18 for stress. The scale has been widely used and
found to be a good measure of psychological distress in both clinical
and general population.
Data collection began as soon as approval was granted by
relevant military authorities in the various locations/barracks. One
of the researchers, a military officer, who actively participated in
the insurgency operation, conducted the recruitment and screening
exercise. The exercise took place in six different military units that
cut across Bauchi, Gombe and Plateau states. The reason for the
choice of these locations was due to the huge presence of returnees
domiciled within these states. Available and eligible returnees who
met inclusion criteria were provided with a participant information
sheet that contained a written description of the study including
the study purpose, procedures, duration, risks, benefits, and the
right to withdraw at any time without penalty. Participants who
read and indicated interest were provided with a standardized
questionnaire to fill under a conducive atmosphere.
In all, six hundred and five (605) respondents were
purposively sampled across the six barracks. The reason for using
purposive sampling was because the study specifically targeted
only military personnel who actively participated in the counter
insurgency operation and met other inclusion criteria. Also, due
to the security situation in the country at the time of conducting
this study and the nature of military job, the use of a randomized
technique was practically impossible. Out of the seven hundred
questionnaires administered, only six hundred and five were
properly filled and returned. Questionnaires not properly filled
were discarded. The study spans for about two weeks after which
completed questionnaires were retrieved and subjected to data
analysis. The Pearson r correlation statistics was used to establish
the relationships between study variables. Statistical Package for
Social Sciences (SPSS-20) was used to analyse data. Particularly,
moderated multiple regression statistics was used to test for the
independent and moderating influence of unit social support
in the relationship between combat exposure, self-efficacy and
psychological distress dimensions.
Ethical Consideration
The study was approved by the Nigerian military authorities
in the various locations sampled. Also, through the information
provided on the questionnaire, respondents were informed that
participation was voluntary, and that the data obtained would
be treated with absolute confidentiality. Participants were duly
consented and briefed about the study before given questionnaires to
fill. To ensure confidentiality and anonymity, all the questionnaire
copies administered were coded without any form of identification.
Only relevant information were collected so as to avoid unnecessary
invasion of their privacy. On the issue of risk, no participant was
meant to incur any physical risk throughout the study. However, the
possibility of minimal economic and social risk, such as stigma and
impact on career prospects, made the researchers to adhere strictly
to the principle of confidentiality. No name or any obvious means
of identification was required. Participation for the study required
no cost and was voluntary and the findings would recommend for
implementation to improve the wellbeing of the officers.
Initial exploratory correlations between the study variables
revealed that combat exposure was negatively associated with
the anxiety (r=.089;<.05) but not the depression (r=.062; >.05)
component of psychological distress. Self-efficacy had a negative
relationship with anxiety (r= -.019; <.05) but was not related
to depression (r=-.016; >.05). Unit social support indicated a
significant negative relationship with anxiety (r= -.120; <.01) and
depression (r= -.115; >.01). There was also a significant positive
relationship between unit social support and self-efficacy (r= -.079;
<.05) (Table 1).
Results in (Table 2) explains the predictive role of combat exposure
and self-efficacy on the two dimensions of distress (Anxiety
and depression) and the moderation role of unit social support
in the relationship between the independent variables and the
dimensions of the dependent variable. On individual influence,
combat exposure independently predicted anxiety (β= .06, t =
1.54, p <0.05) and depression (β= .58, t = 1.54, p <.05). However,
self-efficacy did not predict neither anxiety (β= .01, t = -24, p >.05)
nor depression (β= .09, t -24, p >.05). Under the anxiety model, we
tried to ascertain whether unit social support would moderate the
relationship between combat exposure, self-efficacy and symptoms
of Anxiety and depression. To test the model, the independent
variables and the moderator (Combat exposure, self-efficacy,
unit social support) were regressed on anxiety and depression scores. Result indicated that combat exposure, self-efficacy and
unit support had a significant joint relationship with anxiety
component and accounted for 4% of the variance in the symptoms
of the disorder, R2 = .04, F (3, 601) = 1.44, p <.05. This means that
a moderating relationship may exist among the variables. To test
for moderation, the interaction term between unit social support
and combat exposure, unit social support and self-efficacy were
included into the second model and result indicated a significant
interaction effect, revealing that unit social support moderated the
influence of combat exposure (ΔR2 = .021, β,.08, t, .47; p >.05) and
self-efficacy (ΔR2 = .021, β,-.41, t, -2.00; p >.001) on anxiety.
However, in the model under depression, though all the
independent variables showed a significant joint relationship
with depression R2=.017, F (3,601) = 3.84, p <.05, there was no
interaction effect (ΔR2 = .019, ΔF (5, 596) = .85p > .05). Interactions
between combat exposure and unit social support (β = 0.62, t =
39, p >.05), self-efficacy and unit social support (β= .24, t = 1.19, p
>.05),) on depression were all statistically insignificant. As shown in
(Figure 1), the influence of self-efficacy on anxiety was low at high
level of unit social support compared to when unit social support
was low. Though personnel with low self-efficacy reported lower
symptoms compared to those with high self-efficacy at the initial
stage, when unit support became low, it reversed this relationship.
Thus, at low unit support, military personnel with low coping selfefficacy
reported higher symptoms of anxiety compared to those
with high self-efficacy. This implies that when there is lack or low
availability of support to military veteran during combat, it will
increase their vulnerability Anxiety problems.
The purpose of this paper was to examine relationship
between unit social support and psychological distress (Anxiety
and Depression), determine whether combat exposure and selfefficacy
would predict anxiety and depression and to determine
whether unit social support would moderate the relationship
between combat exposure, self-efficacy and psychological distress
among Nigerian military returnees from Boko-Haram insurgency
in the North-east. From the associations found between unit social
support and the dimensions of psychological distress, result of a
multiple correlation revealed a significant negative relationship
between unit social support and the two dimensions of anxiety
and depression. Conversely, there was a significant negative
relationship between unit social support and self-efficacy in this
study. The findings from this study provided empirical evidence that
increased availability of emotional and instrumental support from
military leaders and colleagues to traumatized combatants during
deployment can increase their ability to manage combat events and
decrease vulnerability to Anxiety and depression. This suggests
that providing relevant support to military personnel while in
theatre may lead to a consequent reduction in their experience of
psychological distress.
In addition, combat exposure predicted all the dimensions of
psychological distress. This implies that exposure to combat events
has the potential to affect both anxiety and depressive symptoms in
military veterans. This finding is in line with Seal, et al, which found
that out of 21% American veterans diagnosed with PTSD,17.4%
had a full diagnosis of depression. However, self-efficacy was
negatively related to anxiety but did not predict neither anxiety nor
depression in the repression model. This imply that though poor
self-efficacy may increase anxiety, it has less strength to predict
any of the dimensions of distress in this population. Unit social
support was also found to moderate the negative effects of combat
on anxiety among the personnel. Though exposure to high combat
events was found to negatively impact anxiety, high availability
of support from colleagues and military leaders attenuated this
impact. Thus, despite the high stress orchestrated by the exposure,
individuals who received high support at combat appeared to
remain calm and unaffected behaviorally or emotionally and tended
to report lower symptoms of anxiety. In all, these findings may
support the findings of Polusyet MA, et al. [22] which found that
American military veteran with low unit social support reported
high posttraumatic stress disorder (PTSD). Similarly, unit social
support also moderated the effect self-efficacy on anxiety such that
at low level of unit support, self-efficacy was inversely related to
manifestation of anxiety problem. This implies that when there is
lack or low availability of support to military veteran during combat,
it will it will increase their vulnerability to anxiety. The findings
enjoys support from Karney BR, et al. [15] who found that social
support has significant role in performance and mental health. This
paper therefore concludes that combat exposure can affect both
anxiety and depression and that unit social support can help reduce
the negative impact of combat and self-efficacy on manifestation
of psychological distress among military personnel in Nigeria.
Therefore, military authorities should provide sufficient support
particularly during combat to boost solders’ confidence and reduce
the deleterious effects of these risk factors on anxiety level of their
personnel so as to enhance their effective performance.
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