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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 38  |  Issue : 2  |  Page : 73-80

Model of coping strategies, resilience, psychological well-being, and perceived health among military personnel


1 Department of Nursing, Tri-Service General Hospital, Taipei, Taiwan
2 National Defense Medical Center, School of Nursing, Taipei, Taiwan

Date of Submission26-May-2017
Date of Decision14-Jan-2018
Date of Acceptance23-Jan-2018
Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Hui-Hsun Chiang
School of Nursing, National Defense Medical Center. No. 161, Sec. 6, Minquan E. Rd., Neihu Dist., Taipei 11490
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmedsci.jmedsci_60_17

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  Abstract 

Background: Military personnel are confronted with physiological and psychological changes caused by stress and exposure to trauma. Although resilience may be protective against psychopathology, very few studies have explored the relationships between the resilience and coping strategies. The study aims to assess how different coping strategies affect resilience, psychological well-being (PWB), and perceived health among military personnel. Subjects and Methods: This study was a cross-sectional survey. Nuclear, biological, and chemical (NBC) soldiers and nurses in the military medical center were recruited in Taiwan in November 2015. The survey comprised the Brief COPE Scale, Ryff's PWB Scale, and the Resilience Scale for Adults, which examined the relationships among coping strategies, PWB, resilience, and perceived health. Path analysis was applied. Results: We recruited 200 participants (145 male and 177 single) aged 24.6 ± 4.7 years (range, 18–46 years). Resilience (coefficient = 0.60, P < 0.001) and PWB (coefficient = 0.33, P < 0.001) were better when using more approach-oriented coping strategies and fewer avoidant coping strategies, whereas the opposite pattern was seen when using avoidant coping (coefficient = −0.31, P < 0.001 for resilience and coefficient = −.20, P < 0.1 for PWB). PWB significantly predicted perceived health (coefficient = 0.45, P < 0.001). Conclusions: Resilience is higher when positive approach-oriented coping strategies are used, which directly affects PWB, and in turn, predicts better-perceived health. Our conceptual model indicates that interventions designed to promote approach-oriented coping strategies may help military personnel develop improved resilience, PWB, and perceived health status.

Keywords: Military nuclear-chemical maneuver, psychological well-being, resilience, stress coping


How to cite this article:
Chen KJ, Yang CC, Chiang HH. Model of coping strategies, resilience, psychological well-being, and perceived health among military personnel. J Med Sci 2018;38:73-80

How to cite this URL:
Chen KJ, Yang CC, Chiang HH. Model of coping strategies, resilience, psychological well-being, and perceived health among military personnel. J Med Sci [serial online] 2018 [cited 2018 Jul 16];38:73-80. Available from: http://www.jmedscindmc.com/text.asp?2018/38/2/73/230014


  Introduction Top


Military personnel feel stressful and have heavy workload when they are on duty [1] and suffer higher rates of mental illness.[2] Their performance is also affected by the exposure to physical and psychological stress, which may impair their health. Resilience, the ability to adapt and adjust to stressful experiences, may generate strength for preventing psychological distress in military personnel,[3] with evidence that it can protect against the negative effects of stressful events.[4] Understanding the attributes of such psychological resilience may be useful in developing preventive strategies.[1],[5]

Resilience is known to predict mental health, with evidence suggesting that positive coping strategies can protect military personnel from the adverse effects of stressful events.[4] Improved resilience may thus be an important target as a defense strength against stress.[6] Previous research indicates that resilience plays an important protective role against psychopathology and may have an ameliorating effect on psychological well-being (PWB) and that positive and negative coping strategies can affect both resilience and mental health. However, PWB is also an important predictor of physical health.[7],[8] In a quantitative review, for example, PWB was shown to be significantly associated with reduced cardiovascular mortality in a healthy population.[9] Evidence also indicates that high PWB and positive emotions strongly contribute to better health outcomes and a longer life.[10]

Effective coping skills for managing military-related stressors are strongly correlated with improved life satisfaction and resilience [11] while coping strategies are known to predict variance in resilience. Task-oriented coping has a positive relationship with resilience, whereas emotion-oriented coping is associated with low resilience.[12] Consequently, resilience boosting can help prevent and treat depression.[13] Other coping styles may also be associated with different psychological distress levels, with evidence that active coping can result in lower depression scores [14] and that avoidant coping can significantly predict alcohol abuse.[5]

However, several studies have produced different outcomes for coping strategies in patients with posttraumatic stress disorder (PTSD). A prospective longitudinal study of risk and resilience among 122 U. S. Air Force medical personnel indicated that repressor coping strategies predicted fewer PTSD symptoms.[15] Another study on 84 male rescue workers in Taiwan similarly showed that job experience and confronted coping are significant predictors of psychiatric morbidity while distancing, escape–avoidance, and positive reappraisal are significant predictors of posttraumatic morbidity degree.[16]

Whereas mental health refers to a state of well-being, wherein a person can use their own abilities to cope with the stressful events or adversity of their life, resilience refers to a person's relative resistance to stress.[17] However, limited research focuses on the relationships among coping strategies, resilience, PWB, and health status in the military personnel.

Nevertheless, despite evidence of convergence in constructs of resilience, PWB, and coping strategies, before this study, there had been little research into the precise relationships among the coping strategies, resilience, PWB, and perceived health status in the military population. Furthermore, despite the proven benefits of resilience and PWB in other groups, we were not aware of any study that explored the relationships between coping strategies, resilience, PWB, and perceived health in a military population. This study aims to assess relations between different coping strategies, resilience, PWB, and perceived health among military personnel.


  Subjects and Methods Top


Study design

In this cross-sectional study, we assessed how different coping strategies affect resilience, PWB, and perceived health among nuclear, biological, and chemical (NBC) protection soldiers and military nurses in Taiwan. Questionnaires were distributed to the participants who met the study criteria in November 2015, and path analysis was adopted to examine the relationships among the variables of the study interest.

Participants

A convenience sample was used to recruit military personnel through purposive sampling. Inclusion criteria were as follows: (1) age 18 years and above; (2) participated in NBC disaster maneuver on military exercise in the past two years; and (3) written informed consent was obtained. NBC disaster is not only a military but a medical issue that needs specific medical instruments to resuscitate lives. NBC disaster maneuver is regularly held on annual military exercise. The original sample consisted of NBC protection soldiers in Taoyuan city, the NBC force of the Northern Taiwan. Clinical nurses we recruited in this study work in the military medical center of Northern Taiwan, and the military medical center held NBC disaster maneuver annually. NBC protection soldiers were recruited from a military force in Northern Taiwan if they consented to participate in this study. The only exclusion criterion was never having received NBC training.

Procedure

The study was reviewed and approved by the Institutional Review Board of the Tri-Service General Hospital (Approval No. 1-105-05-109). The researcher directly approached the selected participants and explained the study aims and the importance of participation and confidentiality. Written informed consent was obtained from the participants who agreed to join this study. The questionnaires were administered to the participants preceded by an information sheet. All responses to the questionnaires were kept confidential.

Instruments

The questionnaire included a demographic information sheet, Ryff's PWB Scale (Ryff's PWB Scale), the Brief COPE Inventory (Brief COPE), and the Resilience Scale for Adults (RSA). Permission was obtained to use the questionnaires. The following demographic data were collected: gender, age, marital status, educational level, income, experience of NBC incident management, and working unit. In addition, perceived health status was assessed by asking “How is your health status?” and ranged from 1 (very bad) to 5 (very good).

Ryff's Psychological Well-Being Scale

We used the shortened version of PWB Scale, which has 6 subscales of 14 items each (7 positively worded and 7 negatively worded). The 6 subscales are autonomy, environmental mastery, personal growth, positive relation with others, purpose in life, and self-acceptance. Cronbach's alpha coefficients for the six sub-scales were 0.82–0.90. Correlations of the 14-item scales with the 20-item original scale range from 0.97-0.98.[18] Responses to each item were on a six-point format, from strongly disagree (one) to strongly agree (six). The Mandarin version of PWB Scale has been shown to have good reliability (α =0.89) and validity.[19]

Resilience scale for adults

The RSA consists of 33 items that measure intra- and inter-personal protective resources that may facilitate adaptation and tolerance to stress and negative life events.[20] The Mandarin version of the RSA consists of 29 items with 5 dimensions and has good validity and reliability (α = 0.89). It comprises five factors: (1) personal strength (six items); (2) family cohesion (seven items); (3) social resources (eight items); (4) social competence (four items); and (5) structured style (four items).[21] Items were scored along a five-point semantic differential scale. The test–retest reliability was good (α = 0.89).[21] Confirmatory factor analysis with five factors of the scale inducted into the conclusion that the five constructed dimensions of the resilience should be kept intact. In the present study, the Cronbach's alphas were 0.86, 0.82, 0.87, 0.85, and 0.90 for the abovementioned five factors, respectively; for the total RSA score, the Cronbach's alpha was 0.95.

Brief COPE Inventory

The full COPE Inventory is a multidimensional self-completed questionnaire assessing coping in response to stress.[22] The brief version is an abbreviated version that comprises 14 subscales for which psychometric properties are described (2 items per scale) with good validity and reliability (α = 0.50–0.90).[23] The Mandarin version of the Brief COPE has acceptable validity and reliability in the present study (α = 0.80). The scale also combines 14 scales into two factors: approach-oriented coping and avoidant coping. The approach-oriented coping dimension consists of five facets with good reliability (α = 0.90), and the avoidant coping dimension consists of six subscales with good reliability (α = 0.74), with the exception of nonsignificant loadings for active coping, humor, and venting.

Statistical analyses

The dataset was examined for accuracy, the amount and pattern of missing responses, and outliers before analysis. The results for PWB Scale, the RSA, and the Brief COPE are presented as means ± standard deviation percentages together with Cronbach's alpha scores (α). These descriptive data were computed using IBM SPSS Statistics for Windows, Version 20.0 (Armonk NY: IBM Corp.)

Data were subsequently analyzed by path analysis to detect the direct and indirect effects between variables of coping strategies, perceived health, PWB, and resilience values. The relationships among the Brief COPE Scale, the PWB Scale, the RSA, and the perceived health were assessed using Mplus software version 5.1. Path analysis is especially appropriate to investigate the empirical and commonsense knowledge of a problem.[24] For this study, we were interested in testing the hypothesis that the Brief COPE is directly and indirectly correlated with the RSA and the PWB Scale and that PWB predicts perceived health. Therefore, we used the statistical approach of path analysis to test the correlations for each variable.

Model fit was evaluated using various criteria. The standardized root mean square residual (SRMR) was used to indicate the standardized difference between the observed and predicted covariances, and the comparative fit index (CFI) was used to indicate the proportion of improvement in the overall fit of the test model relative to a null model that has no relationships among observed variables.[25] The indicators of model fit, for refinement of the model and stopping criteria, were as follows: (1) CFI ≥0.90, (2) root mean square error of approximation (RMSEA) ≤0.06, (3) SRMR ≤0.08,[13] and (4) χ2/df <2.[26]


  Results Top


A total of 200 soldiers and nurses completed the preliminary survey [Table 1]. Most participants were male (n = 145; 72.5%) and single (n = 177; 88.5%). Ages ranged from 18 to 46 years (mean 24.6 ± 4.7 years). The mean length of work experience was 3.31 ± 1.57 years, with most participants reporting 6–12 months' experience (n = 54; 27%).
Table 1: Demographic characteristics (n=200)

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Reliability and validity of the scales

Before performing the data analyses, we tested the reliability of the scales. [Table 2] presents the results of separate factor analyses for the items in each scale. The PWB Scale had good validity and reliability, with alpha coefficients of 0.72–0.88 for the subscales and 0.96 overall. The factor loadings for the six Ryff's PWB Scale dimensions ranged from moderate to high (0.55–0.95). Concerning the RSA, Cronbach's alpha coefficient was 0.95 for the total sample, and the reliability of the five subscales ranged from 0.82 (for family cohesion) to 0.90 (for structured styles). The factor loadings of the five RSA dimensions ranged from moderate to high (0.71–0.99). The Brief COPE had Cronbach's alpha coefficients of 0.90 for approach-oriented coping, 0.74 for avoidant coping, and 0.80 overall, with alphas ranging from low (0.32 for self-distraction) to high (0.83 for substance use). The factor loadings for the five subscales in the approach-oriented coping dimension ranged from moderate to high (0.68–0.79) as did all factor loadings for the avoidant coping dimension (0.46–0.83), except for a low but significant loading for self-distraction (0.32).
Table 2: Descriptive statistics of the measures

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Model of COPE-Resilience Scale for Adults-psychological well-being-perceived health

The path model for this study is shown in [Figure 1]. The model fit statistics of the proposed COPE–RSA–PWB-Perceived Health model were as follows: χ2/df = 1.78/3, P = 0.762 CFI = 1.0, RMSEA = 0.00, 90% confidence interval of RMSEA = 0.00–0.098, and SRMR = 0.015. The proposed model fit was very good, so we concluded that the model was adequate to explain the role of different coping strategies, RSA, PWB, and perceived health.
Figure 1: Model of COPE-Resilience Scale for Adults-psychological well-being and perceived health

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In this study, approach-oriented coping was the most significant positive factor for predicting resilience (coefficient = 0.60, P < 0.001), also significantly explaining PWB (coefficient = 0.33, P < 0.001). By contrast, avoidant coping was a significantly negative factor for predicting resilience (coefficient = −0.31, P < 0.001) and PWB (coefficient = −0.20, P < 0.001). Resilience significantly predicted PWB (coefficient = 0.48, P < 0.001), and PWB was the most significant predictor of perceived health (coefficient = 0.45, P < 0.001) [Figure 1].


  Discussion Top


Key findings

Our findings show that positive coping strategies that lead to greater resilience and PWB are important for military personnel who face occupational stressors. Our conceptual model, consistent with prior literature, proposes that resilience and PWB were associated with different stress coping strategies. Moreover, it seems that improved PWB could improve the status of perceived health. We conclude that approach-oriented coping results in significant positive effects on resilience and PWB, whereas avoidant coping has the opposite effects.

Interpretation

Previous research has shown that increasing resilience among military personnel significantly reduces the odds of them developing depression or PTSD and significantly reduces health-care costs.[27] This is consistent with evidence that resilience plays an important protective role in protecting against psychopathology.[28] However, although numerous studies have indicated that resilience is negatively associated with depression, anxiety, and PTSD among the military population,[29],[30],[31] a few studies have explored the relationships between resilience and PWB.

A study of 512 military service members returning from deployment was done.[4] They showed that soldiers with higher levels of resilience, including hardiness (encompassing control, commitment, and challenge), predicted several indicators of better mental health and lower alcohol use after 6–12 months. Another study focused on the mediating role of resilience among 510 burn patients from 5 general hospitals in Xi'an. The results indicated that resilience is significantly and positively correlated with PWB.[32] Elsewhere, a random cross-sectional telephone survey suggested that early life adversity is significantly associated with a lack of resilience resources, which, in turn, influenced PWB. Indeed, the absence of resilience among participants with adverse childhood experiences is markedly associated with poor PWB.[33]

The study results revealed that resilience significantly predicted PWB. Previous studies have indicated that higher levels of resilience predict better mental health [4] and significantly correlate with well-being.[32] Only one cross-sectional study has shown a negative association between PWB and resilience among participants with adverse childhood experiences;[33] however, this did not show that resilience was a significant predictor of PWB. Based on our research, resilience seems to have an important role in predicting good PWB in military personnel.

PWB and perceived health are correlated. We showed that PWB is an important consideration when assessing perceived health in military personnel. Consistent with our conceptual path, the results suggested that different coping styles significantly predicted resilience and PWB. Although the potential positive effect of approach-oriented coping on resilience and PWB has been described in literature,[12],[13] a few studies have investigated the relationship between coping, resilience, and psychological health among military personnel.[11],[14] Previous studies have shown that PWB strongly predicts physical health among both healthy and ill persons.[9] However, these have also shown that further investigation was needed to understand how resilience relates to PWB and perceived health in military personnel. In our study, PWB was seen as a mediator between resilience and perceived health, with physical health (a key goal of military training) mediated by PWB. Of note, personnel who used approach-oriented coping strategies had better resilience and PWB levels in this study. Indeed, we found that different coping strategies influenced resilience and PWB in different ways. On the one hand, approach-oriented coping significantly predicted positive resilience and PWB. On the other hand, avoidant coping predicted negative resilience and PWB.

In previous studies, similar results were found regarding effective coping, resilience enhancement,[11] and mental health.[13] Problem-solving coping is positively related to higher resilience and lower psychological distress, whereas avoidant coping is negatively related to resilience and mental health.[12],[13],[14] Thus, approach-oriented coping, in which individuals try to eliminate the stressor and modify its external cause, was associated with improved resilience and PWB. This is an interesting finding that is consistent with the literature on the benefits of problem-focused coping.[14] Furthermore, the result emphasizes the importance of resilience and PWB, because by having positive approach-oriented coping strategies, military personnel may develop positive resilience and PWB, which should result in a more positive perception of their health status.

To date, there has only been limited research into the relationship between perceived health and PWB in military populations. Perceived health status, which is a significant indicator of morbidity and physical health, has been shown to be a strong indicator of underlying disease burden.[34] Numerous studies have also indicated that happiness and PWB are strongly associated with perceived health [35],[36] and can protect against illness.[37] However, no study had investigated this issue in a military population until ours, and our results are consistent with those in other populations, confirming that PWB significantly predicts perceived health status in the military population. Our results also indicated that perceived health was only predicted by PWB and that it was not influenced by other coping strategies.


  Conclusions Top


Although PWB is a key component of perceived health, we showed that approach-oriented coping may have beneficial effects on resilience and PWB in military personnel. By contrast, avoidant coping may have deleterious effects on their resilience and PWB, which could impair their perceived health status. This suggests that interventions designed to promote positive resilience may improve PWB and that this may consequently improve perceived health in this population. It is important for the military organizations to develop interventions to promote resilience and PWB in military personnel as part of an overarching drive to improve physical health.

Limitations and future research directions

Despite the robust design and large sample in a clearly defined cohort, several limitations should be considered. First, it should be noted that most empirical research on PWB has been cross-sectional rather than longitudinal. Future research should, therefore, seek to examine the interaction between approach-oriented coping, avoidant coping, resilience, and PWB in a longitudinal study that includes assessment of any possible moderation by resilience. Second, it should be noted that there were significant correlations between avoidant coping and PWB in the path model even though coefficients were small (coefficient = −0.2, P < 0.001). Future research should examine the impact of avoidant coping on PWB in a large military population military. This suggests that some other un-appraised variables may have been important to the observed relationship. Third, the participants were mainly young males, limiting the generalizability of our findings. Finally, the data were derived entirely through self-report measures, so the data will be subject to the usual limitations associated with this research methodology.

Acknowledgment

The study was supported by a grant from the Ministry of National Defense, R.O.C. (MAB-105-073).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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