Personal Well-being and Stress Symptoms in Wives of Iranian Martyrs, Prisoners of wars and Disabled Veterans.

OBJECTIVE: This study was conducted to compare the personal well-being among the wives of Iranian veterans living in the city of Qom.
METHOD: A sample of 300 was randomly selected from a database containing the addresses of veteran's families at Iran's Veterans Foundation in Qom (Bonyad-e-Shahid va Omoore Isargaran). The veterans' wives were divided into three groups: wives of martyrs (killed veterans), wives of prisoners of war, and wives of disabled veterans. The Persian translation of Personal Well-being Index and Stress Symptoms Checklist (SSC) were administered for data collection. Four women chose not to respond to Personal Well-being Index. Data were then analyzed using linear multivariate regression (stepwise method), analysis of variance, and by computing the correlation between variables.
RESULTS: Results showed a negative correlation between well-being and stress symptoms. However, each group demonstrated different levels of stress symptoms. Furthermore, multivariate linear regression in the 3 groups showed that overall satisfaction of life and personal well-being (total score and its domains) could be predicted by different symptoms.
CONCLUSION: Each group experienced different challenges and thus different stress symptoms. Therefore, although they all need help, each group needs to be helped in a different way.

The wives of veterans experience stress during the time they should give care to their husbands and their families (1). The 1980 Equal Opportunities Commission report identifies physical problems related to the exertions of caring for a disabled relative. Women who care for a husband with altered character (for example, as may occur following a head injury or stroke) at home may be predisposed to depression, anxiety and other forms of mental illness (2, 3). Wives of traumatized veterans are one of the various groups who have been identified as suffering psychological consequences of traumatic events, which they did not experience at first hand, but through their close proximity to a direct victim. In a further analysis, Jordan et al. (4) found that the wives of PTSD veterans reported significantly lower happiness and life satisfaction and higher demoralization than the wives of veterans without PTSD. There are many evidences that suggest the veterans’ symptoms continue and even worsen during the years after the war (5–11). Solomon et. al. (12) have found that partners of veterans with PTSD or other combat stress reactions have a greater likelihood of developing their own mental health problems compared to partners of veterans without these stress reactions. In addition, male partners of female Vietnam veterans with PTSD reported poorer subjective well being and more social isolation than partners of female veterans without PTSD. (4). Nelson and Wright (13) indicate that partners of PTSD-diagnosed veterans, often describe difficulty coping with their partner's PTSD symptoms, describe stress because their needs are unmet, and describe experiences of physical and emotional violence.

Partners are keenly aware of cues that precipitate symptoms of PTSD, and partners take an active role in managing and minimizing the effects of these precipitants.Many researchers concluded that there were high levels of caregiver burden included psychological distress, dysphoria, and anxiety(13–15). Studies also suggest that wives of injured men experience more distress than mothers (16–19). A more specific study was carried out by Solomon et al. (12) on 205 wives of Israeli combat veterans of the 1982 Lebanon war providing further evidence of heightened emotional distress among wives of PTSD veterans. Similar findings were obtained on another sample of wives of Israeli war veterans of the Lebanon war some twenty years after (20). It seems that these reactions to give care to the husband partly relate to giving care to a chronic patient and changing normal pattern of family functioning. For example, one study found that women who are caregivers of AIDS patients experience lower emotional well-being (21).

According to a study, the injury alters not only the victim's life but also that of his caregiver (22). They found that 75% of their 38 respondents indicated a significant level of psychological distress. In another study, it is also concluded that 79% of the wives of the men who had sustained brain injuries complained of depression (23).

Researches on family functioning following severe trauma have shown that the lower levels of anxiety among the wives of men with spinal cord injuries is due to the emotional support which is provided by these men(24). Furthermore, many of the wives commented that the rehabilitation process had been focused upon the injured person and had rarely included their wives (25). In addition, caring responsibilities were positively correlated with the amount of pressure reported by working women(26).For example, the mood of wives of chronic obstructive pulmonary disease patients was influenced by their level of stress and social support(27), indicating that the partners' health is interrelated with each other. Finally it is suggested that chronic illness in a partner may negatively affect an individual's physical and mental health (28).

There fore, this study was conducted to test the followings:

Wives of disabled veterans have lower well-being in comparison to wives of martyrs and prisoners of war.

Wives of disabled veterans and martyrs experience more stress than wives of prisoners of war.

Wives of disabled veterans and martyrs show more stress symptoms than wives of prisoners of war.

Materials and Method

Participants

A sample of 296 wives was randomly selected from a database at the “Iranian martyrs and Veterans Affairs Foundation – Qom branch” (IMVAF-Qom). There were 139 wives of prisoners of war; 60 wives of martyrs, whose husbands were killed during the war; and 97 wives of disabled veterans (according to IMVAF classification, based on the severity of the veterans’ disability, they were placed in categories ranging from 25% to 70% and above). The cultural and economical class of the randomly selected participants varied from one another.

Instruments

Personal Well-being Index-Adult (PWI-A)

It is generally agreed that subjective wellbeing (SWB) can be measured through questions of satisfaction directed to people's feelings about themselves (29). It is based on life domain scale in which there is a domain-level representation of global life satisfaction and 7 other domains whose scores are computed as personal well-being. Each item refers to a specific life domain (aspect), and the scores of all items are averaged to produce a measure of SWB. The PWI scale contains seven items of satisfaction, each one corresponding to a quality of life domain as: standard of living, health, achieving in life, relationships, safety, community-connectedness, and future security. These seven domains are theoretically embedded, as representing the first level deconstruction of the global question: “How satisfied are you with your life as a whole?” (29). Its basic psychometric characteristics in Australia have been described (30). Cronbach's alpha lies between .70 and .85 in Australia and overseas (International Well-being Group, 2005). In this study, we computed the Cronbach's alpha of the Persian translation as high as 0/845. PWI-A in this study showed a negative correlation with Family Inventory of Life Events and Changes Scale (31). Its correlation coefficient was -0/178 with 0/002 insignificancy level.

Furthermore, PWI-A showed a negative correlation as high as 0/498 with Stress-related Symptoms Checklist – alpha=0/0001.

Family Inventory of Life Events and Changes

Prior stressors, strains, and transitions were measured with the Family Inventory of Life Events and Changes. This scale has 71 items in 9 sub-scales that assess life events in the general areas of family conflicts, marital relations, births/pregnancies, money, jobs, moves, deaths, and other; and was developed by McCubbin, Patterson &Wilson (31). This self-report instrument was designed to assess both the normative and non-normative family life events, transitions, and strains a family unit may have experienced during the past year. Higher scores indicate greater stress. The alpha coefficient for the total scale was reported as .81, and test-retest reliability was reported as .80.The overall reliability was reported as high as 0/83(32) and its reliability for mothers has been reported to be up to 0/87, and for fathers from 0/70 to 0/83 (33). In this study, the test-retest reliability was 0/722.

Stress-related Symptoms Inventory

It included 41 stress-related symptoms which were adopted from the 56 ones of Casanova-Rosado et. al. (34).In this study, Stress-related Symptom Inventory showed a positive correlation with Family Inventory of Life Events and Changes Scale as high as 0/19 (in 0/001 significancy level) and negative correlation (0/498) with PWI.

Procedure

a) A complete list of wives of martyrs, prisoners of war, and wives of disabled veterans was gathered from the Iran's Veterans Foundation in Qom (Bonyad-e-Shahid va Omoore Isargaran). Then, the types of husbands' conditions were defined. A random sample was prepared from the four urban and educational districts of this city.

Wives of these people were informed that the Iranian Veterans Foundation is intending to reveal the psychological problems of the families and their consequences.

The researcher of this study (the corresponding author) was also serving these families as a social psychologist for several years and was well-known to them.

After providing the primary information regarding the study through telephone, the visit times were defined; and educated interviewers as well as researchers were sent to the subjects' houses. Then, the interviewers asked the subjects to complete the questioners. For those un educated or low educated subjects, completion of questionnaires was performed through an oral procedure similar to the Wexler test of intelligence.

b) Regarding the ethical principal of the research procedures, it should be mentioned that the interviewers presented a written introduction about themselves, and no personal indicator of samples was registered in the questionnaires. The subjects were familiar with the chief researcher of the study as a clinical physiologist. No responsibility or promise was assumed for the subjects.

c) No awards were promised for such voluntary participation of the samples and they just participated in the study based on their familiarity with the researcher and feeling of confidence regarding them.

d) Inclusion criteria were the type of the husband's situation and his residence site.

Exclusion Criteria were death (1 case), displacement or movement to another city (2 cases).

We used computerized random sampling in veterans' data bank at the “Iranian Martyrs and Veterans Affairs Foundation- Qom branch” (IMVAF-Qom). Next, each participant was called by a trained graduated psychologist and upon the subject's approval; she was paid a visit at her home, where the psychologist executed the measures. Our psychologists presented every participant with an invitation letter describing the aim of the research to inspire their participation. This study is an ex-post facto research design.

Statistical analysis

To compare the three groups of the participants, we used ANOVA. Furthermore, linear multivariate regression analysis (stepwise method) was used to find out which variable could predict personal well-being.

Results

In this study, 296 wives participated, as shown in Table 1.

Table 1

Frequency of participant groups

group	frequency	Percentage
Prison of wars' wives	139	47%
Martyrs' wives	60	20.3%
Disabled veterans' wives	97	32.7%
total	296	100%

As we can seedemonstrated in Table 2, there is no significant difference between the three groups in their overall satisfaction of life. Wives of martyrs (killed veterans), disabled veterans and prisoners of war have shown almost equal overall satisfaction of life. However, their personal well-being, family stresses and stress-related symptoms differ significantly. These differences have beenare shown in graph 1.

Table 2

ANOVA results to comparing groups

	Sum of Squares	df	Mean Square	F	Sig.
Overall life satisfaction	5.141	2	2.620	0.300	0.741
Personal well-being	1703.387	2	851.689	3.393	0.035
Total family stress score	112348.358	2	56174.179	18.833	0.0001
Stress-related symptoms score	6925.584	2	3462.792	4.705	0.010

Independent variables include, stress and stress symptoms.

Independent variables includes well-being of Wives of disabled veterans,

In graph 1, we seeit can be seen that the wives of disabled veterans experience the lowest level of personal well-being, whereas, both. However, the wives of prisoners of war and martyrs are on the same level, which is higher in comparison to the wives of disabled veterans. The wives of prisoners of war suffer from higher levels of family stress, while the other two groups of wives experience lower levels of family stress. For stress-related symptoms, the wives of martyrs are at the highest level followed by the wives of disabled veterans in the middle, and finally the lowest level belongs to the wives of prisoners of war. By looking at the graph 1, we can see that the wives of prisoners of war experience a high level of family stress while showing the least amount of stress-related symptoms and feeling the highest personal well-being. Although the wives of killed veterans also show a high level of personal well-being, but they experience a low level of family stress and show the highest level of stress-related symptoms. Finally, the wives of disabled veterans experience a low level of family stress, but show a high level of stress-related symptoms and feel the lowest level of personal well-being. We will discuss these findings later.

To assess variance predictions, we used linear multivariate regression analysis in which the total score of family stress is the dependent variable and the nine family sources of stress are the independent variables. According toAs demonstrated in Table 3, in all the participants, family conflicts predicted 94.6% of the total score of the Family Inventory of Life Events and Changes. Other sub-scales have shown minor predictions. It seems that family conflicts are the main source of stress in the life of all the wives of veterans' wives. Now, we must see whether all the three groups have a unique main source of stress in their families.

Table 3

Linear multivariate regression analysis (stepwise method)

Predictor	R Square	F	Sig. of F	B	Beta	T	Sig.
Family conflicts	0/946	5116/596	0/0001	1/090	0/277	18/378	0/0001
Marital relations	0/975	5668/441	0/0001	1/123	0/272	19/336	0/0001
Births/Pregnancies	0/984	6097/897	0/0001	1/078	0/144	12/523	0/0001
Money	0/989	6554/730	0/0001	1/237	0/087	8/034	0/0001
Jobs	0/991	6810/685	0/0001	0/911	0/114	11/751	0/0001
Family care giving	0/993	7048/590	0/0001	1/106	0/063	7/318	0/0001
Loss	0/994	6744/629	0/0001	1/389	0/058	4/759	0/0001
Moves from & to home	0/994	6174/349	0/0001	0/847	0/032	3/777	0/0001
Problems with law	0/994	5569/943	0/0001	0/360	0/015	2/289	0/0001

To evaluate the predictors of personal well-being among the three groups of participants, a linear multivariate regression analysis (stepwise method) was executed in which discriminative events among participants entered the regression equation. Its The results have are shown in Table 4.

Table 4

Linear multivariate regression analysis (stepwise method) in wives of prisoners of war

Predictor	R Square	F	Sig. of F	B	Beta	T	Sig.
Automatic Thoughts	0/270	108/786	0/0001	−2/750	−0/407	−8/135	0/0001
Chronic Stress Symptoms	0/370	85/954	0/0001	−0/188	−0/323	−6/481	0/0001
Be the wife of disabled veteran	0/399	64/537	0/0001	−5/848	−0/172	−3/748	0/0001

As we can see, automatic thoughts, and chronic stress symptoms and be among the wives of disabled veterans' wives predict personal well-being scores.

The family stressors are different in each group of wives. In tTable 5, we can see demonstrates that the wives of prisoners of war experience the most amount of family stresses because of economic limitations (R Square= 0/962). Family conflicts are in second place predicting 2% of the total score. Other sources of stress had the lowest effects in the Family Life Events and Changes had the lowest effects.

Table 5

Linear multivariate regression analysis (stepwise method) in wives of prisoners of war

Predictor	R Square	F	Sig. of F	B	Beta	T	Sig.
Money	0/962	1698/421	0/0001	1/208	0/300	13/759	0/0001
Family conflicts	0/982	1833/729	0/0001	1/127	0/287	13/270	0/0001
Jobs	0/989	2107/750	0/0001	1/040	0/147	8/413	0/0001
Loss	0/993	6554/830	0/0001	1/432	0/100	6/497	0/0001
Family care giving	0/995	2527/747	0/0001	0/851	0/114	7/612	0/0001
Moves from & to home	0/996	2583/821	0/0001	0/934	0/051	4/134	0/0001
Problems with law	0/996	2605/193	0/0001	1/091	0/046	2/865	0/005
Births/Pregnancies	0/996	2193/088	0/0001	0/899	0/035	2/813	0/006

The main source of stress for the wives of killed veterans (martyrs) was legal problems (problem with law). According to Table 6, legal problems of one of the family members have predicted 98.6% of variances of the Family Life Events and Changes' score. Economic stresses are is the second source of their family stresses. Different from the other two groups, fFamily conflicts are the main source of family stresses for the wives of disabled veterans.

Table 6

Linear multivariate regression analysis (stepwise method) in wives of killed veterans

Predictor	R Square	F	Sig. of F	B	Beta	T	Sig.
Problems with law	0/986	1989/742	0/0001	4/638	0/193	2/185	0/033
Money	0/991	1557/708	0/0001	0/723	0/182	4/993	0/0001
Family care giving	0/992	1197/881	0/0001	0/986	0/108	4/744	0/0001
Jobs	0/994	1099/437	0/0001	1/101	0/137	4/127	0/0001
Family conflicts	0/995	1025/927	0/0001	0/746	0/181	3/707	0/001
Moves from & to home	0/996	1058/488	0/0001	1/377	0/093	3/826	0/0001
Loss	0/996	969/724	0/0001	2/347	0/155	2/147	0/036

Comparing three groups in overall life satisfaction, personal well-being, total family stress score and chronic stress symptoms score (P values: overall satisfaction: .741; personal well-being: .035; total family stress scores: .0001; chronic stress symptoms scores: .01)

Family conflicts have predicted 98.1% of variances of the total score of Family Inventory of Life Events and Changes.

Next in line, we see are the economic problems causing family stresses. Results have been shown in Table 7.

Table 7

Linear multivariate regression analysis (stepwise method) in wives of disabled veterans

Predictor	R Square	F	Sig. of F	B	Beta	T	Sig.
Family conflicts	0/981	2422/896	0/0001	1/147	0/303	13/843	0/0001
Money	0/994	4035/540	0/0001	1/056	0/245	10/865	0/0001
Problems with law	0/996	4319/458	0/0001	1/863	0/077	4/103	0/0001
Loss	0/997	4143/064	0/0001	0/915	0/069	4/919	0/0001
Jobs	0/998	3776/391	0/0001	0/831	0/100	6/171	0/0001
Family care giving	0/998	3794/653	0/0001	0/846	0/105	6/916	0/0001
Moves from & to home	0/998	3938/155	0/0001	1/514	0/089	5/592	0/0001
Births/Pregnancies	0/999	4115/273	0/0001	1/415	0/057	4/270	0/0001

First, we compared personal well-being, overall satisfaction of life, family stresses and stress-related symptoms, in the three groups of participants The results are displayed in Table 1.

Discussion

Whether it is the “death instinct” that drives the nations into wars, or whether there are other complicated reasons for this horrific phenomenon, it seems that wars have become a part of our lives. No matter how offensive or defensive, wars always bring humans unimaginable heartache and misery. Many of the negative effects start to surface in post-war generations. Three decades ago, when Iranians were so busy trying to get their lives together after a revolution in their country, they had to enter an eight-year war with Saddam's regime in Iraq. Although men are the ones fighting at the frontline, women also experience their share of war-related stresses. Some of the war-related sources of stress for women include: providing care for the disabled veterans, looking after children, managing the household, and finally putting up with their husbands’ PTSD. Studies suggest that wives of injured men experience more distress than mothers and that the impact of a traumatic injury upon a marriage partnership is different from the impact upon a parent-child relationship (16–19).

Findings from many researches suggest that the veterans’ wives experience more stress, show more stress-related symptoms and have a poorer quality of life; in another words, they have lower subjective well-being (22, 28, 35–37).

Just as Whalley Hammell (25) reported, the rehabilitation processes had been focused mainly on the injured person and had rarely included their wives in Iran. Wives of disabled veterans only receive a monthly nursing fee and an ordinary insurance without any complementary insurance (unlike the disabled veterans). Furthermore, THe wives of prisoners of war rarely receive instruction in rehabilitation skills, whereas wives of killed veterans (martyrs) can have psychological counseling services, although they don't exactly look forward to these services!

In this study, all the three groups showed similar overall satisfaction of life, but different levels of personal well-being, family stresses and stress-related symptoms. First of all, it seems that they are experiencing a form of “acquired hopelessness” as a result of having to confront constant sources of stress for a long time without ever learning the coping skills in systematic ways, consequently losing their homeostasis. Second, due to Iranian-Islamic culture, they have overused positive reassessment of their difficult situation, meaning that they have focused on figuring out the “Hikmah” for their problems, trying to find positive reasons to justify their sufferings and stresses. Third, they believe that enduring stresses is a way of defending their Islamic beliefs and government and so may be good as it makes God happy.

However, there are some differences among the wives. For example, although the wives of disabled veterans show more stress-related symptoms and experience the least amount of personal well-being, according to many studies, in comparison to the wives of prisoners of war, they experience the least amount of family stress. Partial social isolation of these families has decreased their general social support. Furthermore, veterans' secondary health problems have produced family conflicts in the families of disabled veterans. Anger, low sexual function, physical and other psychological problems increase the conflicts in these families. Although the wives of killed veterans have their own family conflicts, the difference is that they have gradually accepted their conditions without having to experience the hassles of taking care of a veteran with health problems. Therefore, they are usually involved in handling problems caused as a result of the absence of a father in the family. For instance, as the heads of their families, they might have to deal with legal problems. Finally, there are the wives of prisoners of war whose families seem to somehow function more naturally. Their husbands work outside home and have less physical and psychological health problems. Although their husbands have some problems such as PTSD symptoms, their symptoms are milder than those of disabled veterans. One of their advantages is the ability to find work and have earnings. Their problems arise from the fact that they have some health problems after all, and also they have relatively higher expectations. It also seems that they demonstrate displaced aggression by taking their negative reactions to society out on their family members. Therefore, their wives experience more stress and enjoy less personal well-being. At the same time, semi-natural family functioning and homeostasis have helped the wives of prisoners of war to cope with sources of stress better than the wives of disabled veterans and killed veterans.

Limitations

Gathering the needed official data was not easy because of some limitation from the related organizations and the researcher had to obtain different legal grands for accessing such data.

Financial problems were another limitation of this study as the researchers did many of the processes of the research by themselves.