Abstract
Introduction:
Seeking treatment for posttraumatic stress disorder (PTSD) distress can be complicated by a variety of internal and external factors that prevent an individual from seeking care and treatment while distress worsens. This is especially true for hidden populations with an extensive trauma history, such as UK Armed Forces Veterans residing in Northern Ireland. This study aimed to determine the contribution of barriers to care and cumulative trauma exposure to the severity of PTSD symptomatology, the extent of that contribution, and whether variance existed in the specific types of barriers.
Methods:
Data from 657 Veterans residing in Northern Ireland (90.6% male) taken from the Northern Ireland Veterans Health and Wellbeing Study were used in a series of regression models to explore the relationships among cumulative trauma exposure, barriers to care, specific barrier types, and PTSD symptomatology.
Results:
Overall barriers to care and cumulative trauma exposure predicted PTSD (β = 0.385), as did, to a lesser degree, logistical barriers (β = 0.348), trust barriers (β = 0.258), and stigmatic barriers (β = 0.298).
Discussion:
The accumulation of multiple trauma exposures and experiences is strongly associated with PTSD symptomatology, with barriers to care having a significant impact on distress. Overall barriers, specific subtypes of barriers, and trauma contributed to PTSD in this population of UK Armed Forces Veterans residing in Northern Ireland.
Key words: barriers to care, Northern Ireland, posttraumatic stress disorder, PTSD, Veterans
Lay Summary
The Northern Ireland (NI) population has high rates of trauma exposure and posttraumatic stress disorder (PTSD) but many barriers prevent people from seeking help/care, which can worsen mental health conditions. For Veterans, these barriers can include a lack of access to or availability of services, a lack of trust in the mental health system, and stigma — negative beliefs about themselves if they were to seek help. Additionally, many UK Armed Forces veterans in Northern Ireland choose not to disclose Veteran status because of security concerns. The Armed Forces Covenant promises available, accessible, and guaranteed care to service members and Veterans, but the covenant is not in place in Northern Ireland, leaving NI Veterans in need without support and relying on charity organizations. This study explored the relationship among trauma exposure, PTSD, and barriers to care among NI Veterans. Analysis showed that an increased number of traumatic event exposures and increased barriers to care predicted a higher amount of PTSD symptoms and distress, meaning the more trauma a Veteran witnessed or experienced and the more barriers preventing them from seeking care, the worse their mental health was likely to be.
Abstract
Introduction :
La quête d’un traitement pour la détresse liée au trouble de stress posttraumatique (TSPT) peut être compliquée par une variété de facteurs internes et externes empêchant de trouver les soins et le traitement requis alors même que la détresse s’aggrave. C’est le cas en particulier de populations cachées ayant une lourde histoire traumatique, comme celle des vétéran(e)s des Forces armées britanniques vivant en Irlande du Nord. Cette étude visait à déterminer la contribution particulière des obstacles aux soins et d’une exposition cumulée aux traumatismes à la gravité des symptômes de TSPT, ainsi que l’étendue de cette contribution et l’existence d’une variance dans les types spécifiques d’obstacles.
Méthodologie :
Les données de 657 vétéran(e)s résidant en Irlande du Nord (des hommes, à 90,6 %), tirées de l’Étude sur la santé et le bien-être des vétéran(e)s d’Irlande du Nord, ont été employées dans une série de modèles de régression dans le but d’explorer les relations entre l’exposition cumulative aux traumatismes, les obstacles aux soins, les types d’obstacles particuliers et la symptomatologie du TSPT.
Résultats :
Dans l’ensemble, les obstacles aux soins et l’exposition cumulative aux traumatismes ont prédit le TSPT (β = 0,385), tout comme l’ont fait, dans une moindre mesure, les obstacles logistiques (β = 0,348), les obstacles liés à la confiance (β = 0,258) et les obstacles liés à la stigmatisation (β = 0,298).
Discussion :
Le cumul d’expositions et d’expériences traumatiques multiples est fortement associé à la symptomatologie du TSPT et les obstacles aux soins ont un effet significatif sur la détresse. Les obstacles pris dans leur ensemble, les sous-types particuliers d’obstacles et les traumatismes contribuent au TSPT dans la population étudiée.
Mots clés : Irlande du Nord, obstacles aux soins, trouble de stress posttraumatique, TSPT, vétéran(e)s
Introduction
At the Northern Ireland (NI) population level, local residents and Veterans have a high rate of both trauma exposure and associated psychological conditions, including posttraumatic stress disorder (PTSD).1–6 Seeking help for mental distress may seem like an obvious course of action when stress levels become unmanageable; however, the divide between intent and actual treatment seeking can be difficult to cross. Indeed, barriers to care exist that may delay and impede both help-seeking behaviour and access to care, which, in turn, can negatively affect distress and treatment outcomes.7 For populations routinely exposed to trauma, such as armed forces Veterans, impediments to help seeking have a staggering toll on psychological well-being.8–9 These barriers can be internally driven, such as the self-stigmatic belief that friends and family will think the individual is weak for seeking help or a lack of trust in the mental health system.10–13 Barriers can also be external if services are inaccessible.14 Location, transportation, and scheduling difficulties are often barriers to support seeking for Veterans.15
Help-seeking barriers are especially pertinent for UK Veterans residing in Northern Ireland. This is primarily attributable to the country’s complex history of conflict, which culminated in a protracted period of sectarian violence and politically motivated unrest known as the Troubles. Active UK military involvement in the Troubles, known as Operation BANNER (1969–2007), saw an estimated 300,000 service personnel (known as the Home Services) deployed in combat roles,16 approximately 19,500 of whom were native to Northern Ireland and were actively deployed near, or within, the towns and communities where they were raised.17 Nearly 25 years after the conflict formally ended in a ceasefire (the Good Friday Agreement), sectarian divisions remain in many parts of the country as part of the Troubles’ legacy. Thus, serving in the UK Armed Forces continues to carry a significant security risk.17 This leaves many NI Veterans reluctant to disclose their military Veteran identities, and many adopt a hidden status.18–19 Non-disclosure and hiding for their own safety are unique impediments to receiving help for issues that relate to service.
The promise of available, accessible, and guaranteed care to service members by the UK Armed Forces Covenant cannot be implemented in Northern Ireland,20 nor is the devolved NI government given any power in matters of defence, leaving NI Veterans without institutional or statutory support. Although approximately 19 registered charitable organizations in the region offer support and resources specific to this population, half are UK-wide groups with head offices located in Great Britain. Moreover, 19 is a small number compared with the 1,818 bespoke groups situated across England and Wales and the 461 organizations in Scotland.21–22 The creation of a centralized, dedicated Veterans’ centre offering multiple support resources, access to programs, and safe social spaces has long been discussed but has been hampered by concerns over funding, security, and whether Veterans will feel secure using such a facility.
Veterans residing in Northern Ireland also face NI-specific barriers to care involving stigma and a lack of trust in the mental health care system. Both internalized stigma and stigmatic beliefs about mental health treatment are significant deterrents to help seeking across the overall NI population,23–24 and the military culture of mental health stigmatization across the UK Armed Forces only compounds the issue.25–27 Security concerns around Veteran identity result in a profound lack of trust in support systems and have led to reduced help-seeking behaviour.1 In turn, decreased use of support is used to justify the insufficient resources made available for NI Veterans and for continuing the status quo,22 despite evidence of increased need in Northern Ireland compared with the size of the Veteran population.28 If Veterans residing in Northern Ireland have a heightened risk of poorer mental health and simultaneously have support service accessibility issues, this could potentially worsen mental health.
Although not constituting formal barriers to care, Veterans residing in NI were found to be older, face increased disadvantages when compared with Veterans residing in the other UK nations, and have reported worse physical health in studies featuring clinical samples.29–30 Specifically, the reported rate of PTSD among Veterans residing in Northern Ireland (36.8%) was found to be much higher than that found among all UK Veterans (6.2%).1,31 Unfortunately, participant security concerns have hindered most research into the general NI Veteran population, with the Northern Ireland Veterans Health and Wellbeing Study (NIVHWS) being the first to conduct an in-depth examination of mental and physical health, well-being, and specific support needs of this population. Although it is estimated that 150,000 UK Veterans live in Northern Ireland,32 the exact size and socio-demographic descriptors of the population remain unknown. Currently, the question is not asked as part of the census, and, with freedom of movement across the nations, records relating to addresses on transition are unreliable.
Finally, one aim of the NIVHWS was to assess interest in, and need for, a Veterans’ centre (or a number of smaller hubs) that could provide a centralized, secure location for a variety of services, ranging from social activities and residential services to formal and informal mental health support.22 Because access to services can constitute a significant barrier to care, this study was interested in the participants’ attitudes toward a potential Veterans’ centre and their preferred services at such a location. In the time since the NIVHWS, the charity organization Beyond the Battlefield has made a concerted effort to plan, fundraise for, and construct Harbour House, a Veterans’ centre in Portavogie, County Down, which opened in late 2022 and features respite accommodations, social spaces, and a café and eatery.
This study was the first to examine barriers to care in a non-clinical NI Veteran population and predicted a relationship among cumulative trauma exposure, PTSD symptom severity, and barriers to care. Data from the NIVHWS were used to determine 1) whether barriers to care and cumulative trauma exposure predicted PTSD symptomatology, 2) the extent of the contribution of these barriers to distress, and 3) whether specific types of barriers had a greater or lesser contribution. A series of regression models were run to test the overall effect of this model in a population of UK Armed Forces Veterans residing in Northern Ireland.
Methods
Sample data
Data for this study were collected between December 2017 and June 2019 through a cross-sectional, self-report survey of UK Armed Forces Veterans residing in Northern Ireland. The survey was advertised through social media and local organizations working with Veterans. Recruitment emails and text messages were also sent directly to Veterans who had previously engaged with the research team as part of the NIVHWS and agreed to participate in further research. Questionnaires were available online and in pen-and-paper format. Initially, 3,521 respondents entered the study, but 2,105 did not provide full informed consent and were removed, along with an additional 87 responses (n = 1, research team test response, n = 80, no or demographics-only responses, and n = 6, did not meet study criteria), leaving an eligible sample of 1,329 participants. The effective sample for the current study was 657 participants who completed all measures used in the analyses.
Data were taken from the NIVHWS,1 with original ethical approval initially granted by Ulster University (REC/17/0031). The principal investigator (CA) relocated; thus, confirmational approval was subsequently granted by the Queen’s University Belfast Research Ethics Committee (EPS 19_156).
Measures
Exposure to traumatic events was measured with the Stressful Life Events Screening Questionnaire (SLESQ),33 a 13-item scale describing potentially traumatic incidents (“Was physical force or a weapon ever used against you in a robbery or mugging?”), with an additional 4 items taken from the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; LEC-5).34 Items were combined to ensure adequate coverage of the range of lifetime traumatic experiences, including those historically present in Northern Ireland and linked to the Troubles. This combination showed efficacy in previous studies.6,35 Items were scored as binary (0 = no, 1 = yes) and summed to produce a score indicating the total number of traumatic events (cumulative trauma) a participant experienced or was exposed to.
PTSD symptomatology was measured with the PTSD Checklist for DSM-5 (PCL-5),36 a 20-item, self-report scale measuring distress associated with symptoms of PTSD per DSM-5 criteria within the previous month. Participants were asked to consider their worst traumatic experience from the LEC-5 trauma inventory when completing the PCL-5. Each scale item was measured via a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). All responses were summed, and a summative PCL-5 score of 33 or higher is generally accepted as indicative of probable PTSD in the absence of clinical assessment.37 Reliability for the PCL-5 in this study was excellent (α = 0.975).
Barriers to care were measured with a scale adapted from other measures to suit the unique situation in Northern Ireland. Items 1–10 were adapted from Hoge et al. and were originally used in a study of treatment-seeking Veterans in the United States and with a university sample.38,39 One item was removed from the Britt et al. adaption because it was not applicable in the United Kingdom (“Getting treatment costs too much money”),39 and language was clarified for use in the UK context (i.e., replacing “my peers” with “my family, friends, or peers”). Items 11–15 were adapted from Brown et al. and tested with combat Veterans returning from deployment.40 Items 1–4 described perceived logistical barriers, such as lack of transportation and time off work. Items 5–10 described barriers associated with stigma, including external and self-stigma, and items 11–15 described barriers stemming from a lack of trust in mental health care and health care professionals (Table 1). Participants were presented with each statement and asked to what extent they agreed with it, rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with a higher score indicative of greater barriers to care. Reliability for the complete measure was high (α = 0.90), with subscales ranging from high to moderate (Stigma, α = 0.92, Trust, α = 0.80, Logistics, α = 0.70).
Table 1.
Items, subscales, and descriptive statistics for barriers to care measure
| Subscales | Range | Mean (SD) | N |
|---|---|---|---|
| Logistics |
4–20 |
9.36 (3.76) |
798 |
| 1. I don’t know where to get help. | 1–5 | 2.59 (1.34) | 811 |
| 2. I don’t have adequate transportation. | 1–5 | 1.74 (1.13) | 805 |
| 3. It is difficult to schedule an appointment. | 1–5 | 2.78 (1.36) | 805 |
| 4. There would be difficulty getting time off work or my studies for treatment. |
1–5 |
2.30 (1.37) |
800 |
| Stigma |
6–30 |
15.24 (6.88) |
796 |
| 5. It would be too embarrassing. | 1–5 | 2.75 (1.39) | 799 |
| 6. It would harm my reputation. | 1–5 | 2.58 (1.37) | 800 |
| 7. My family, friends or peers might treat me differently. | 1–5 | 2.55 (1.37) | 802 |
| 8. I would be seen as weak. | 1–5 | 2.75 (1.43) | 805 |
| 9. My family, friends, or peers would blame me for the problem. | 1–5 | 2.23 (1.22) | 804 |
| 10. People important to me would think less of me. |
1–5 |
2.39 (1.34) |
805 |
| Trust |
5–25 |
12.36 (4.83) |
800 |
| 11. Mental health therapy/counselling doesn’t work. | 1–5 | 2.35 (1.14) | 805 |
| 12. The mental health care system doesn’t work. | 1–5 | 2.98 (1.29) | 804 |
| 13. My visit would not remain confidential. | 1–5 | 2.45 (1.35) | 802 |
| 14. I don’t trust mental health professionals. | 1–5 | 2.32 (1.24) | 805 |
| 15. I would have concerns about disclosing my Veteran status to my GP. | 1–5 | 2.28 (1.41) | 806 |
Note: Scale N indicates number of participants who endorsed each item; due to missingness, study sample size differs.
GP = general practitioner.
Age was assessed with a single item and used here as a scale variable. Gender was also assessed with a single item and was used as a binary variable. Finally, relationship status was determined with a single item and recoded as a binary variable (married or in a relationship recoded to 1 = in a relationship, single or never married, separated or divorced, and widowed recoded to 0 = not in a relationship, and other [n = 1] recoded to missing).
Attitudes toward and opinions on a Veterans’ centre in Northern Ireland were assessed by a gateway item (“Would you support the development of a Veterans Centre in NI?”) that was scored on a 5-point Likert scale ranging from 1 (definitely yes) to 5 (definitely no). For use in this analysis, definitely no and probably no were recoded to 0 = no. Unsure was recoded to 1 = unsure, and definitely yes and probably yes were recoded to 2 = yes. Participants were provided with a list of services a potential Veterans’ centre might offer and instructed to select all the services they would use. These potential services were not strictly defined, because the aim of this item was to measure interest in broad categories of possible services (i.e., mental health support could include a range of formal treatment options and informal services: social activities, mental health support, physiotherapy, residential services, education and training, gym facilities, peer support, advocacy, and other [a text field was provided for write-in responses]). Finally, participants were provided with a list of reasons why they might not feel comfortable visiting a potential Veterans’ centre and instructed to select all options that applied: don’t need one, don’t want to be reminded of the military, prefer to use the mainstream services, security concerns and risks, transport and other access issues, and other (text field provided for write-in responses).
Analytic strategy
Multiple regression analyses were performed to examine the relationship among cumulative trauma, barriers to care, and PTSD symptomatology, with both unadjusted and adjusted models. Unadjusted models included three control variables (age, gender, and relationship status), with any significant variables retained for the adjusted model. All analyses were run with IBM SPSS Statistics (version 28).41
Results
The sample was described 90.6% male (595 men, 62 women) with a mean age of 55.14 years (SD 10.67), predominantly white (99.2%), heterosexual (98.2%), Christian (73.8%; includes Protestant, Catholic, and other Christian), and in a relationship (73.4%). Most of the sample served in the army (n = 569; 86.6%), followed by the navy (n = 69; 10.5%), Royal Air Force (n = 55; 8.4%), and Royal Marines (n = 12; 1.8%), with some participants serving in more than one branch.
On the topic of a potential Veterans’ centre in Northern Ireland, 81.7% (n = 537) were broadly in favour, 12.2% (n = 80) were unsure, and 6.1% (n = 40) were broadly not in favour. Endorsement rates of preferred services for the potential Veterans’ centre, and reasons why participants might not use one, are given in Table 2.
Table 2.
Endorsement rates for preferred services and detractors (N = 657)
| Services and detractors | No. (%) |
|---|---|
| Preferred services | |
| Social activities | 423 (64.4) |
| Mental health support | 424 (64.5) |
| Physiotherapy | 346 (52.7) |
| Residential services | 181 (27.5) |
| Education and training | 398 (60.6) |
| Gym facilities | 258 (39.3) |
| Peer support | 343 (52.2) |
| Advocacy | 232 (35.3) |
| Detractors for use | |
| Don’t need one | 65 (9.9) |
| Don’t want to be reminded of the military | 18 (2.7) |
| Prefer to use mainstream public services | 27 (4.1) |
| Security concerns and risks | 274 (41.7) |
| Transport and other access issues | 96 (14.6) |
Descriptive statistics for the measures used in the analyses are shown in Table 3. Additionally, 57.4% (n = 377) reported that their worst traumatic event was related to military service.
Table 3.
Descriptive statistics
| Metric | Range | Mean (SD) |
|---|---|---|
| No. of traumas | 0–17 | 7.17 (2.74) |
| PCL-5 | 0–80 | 29.52 (23.31) |
| Barriers | 15–68 | 37.28 (12.98) |
| Logistics | 4–20 | 9.40 (3.79) |
| Stigma | 6–30 | 15.45 (7.01) |
| Trust | 5–25 | 12.44 (4.85) |
PCL-5 = PTSD Checklist for DSM-5.
A series of multiple regression models were run to determine the contribution of variables of interest to PTSD symptomatology. Table 4 shows the results of the regression models exploring total barriers to care. Age, gender, and relationship status were not significant predictors and were not retained in the adjusted model, which showed cumulative trauma and total barriers to care predicting increased PTSD symptomatology, F2, 647 = 120.934, p < 0.001, R2 = 0.270, with both significant at the < 0.001 level.
Table 4.
Results of unadjusted and adjusted regression models for total barriers to care
| Model | t 5 | p | β | F | df | p | Adjusted R2 |
|---|---|---|---|---|---|---|---|
| Total barriers | |||||||
| Unadjusted model | 50.257 | 5, 640 | <0.001 | 0.276 | |||
| Age | −1.783 | 0.075 | −0.062 | ||||
| Gender | −1.774 | 0.077 | −0.061 | ||||
| Relationship status | −0.917 | 0.360 | −0.031 | ||||
| Cumulative trauma | 8.149 | <0.001* | 0.280 | ||||
| Total barriers to care | 10.661 | <0.001* | 0.376 | ||||
| Adjusted model | 120.934 | 2, 647 | <0.001 | 0.270 | |||
| Cumulative trauma | 8.448 | <0.001* | 0.288 | ||||
| Total barriers to care | 11.274 | < 0.001† | 0.385 |
* p < 0.001.
†>p < 0.01
Tables 5–7 show the results of the models exploring logistical, stigmatic, and trust barriers to care, respectively. Age was a significant predictor in each regression and was retained in all adjusted models. Table 5 shows age, cumulative trauma, and logistical barriers predicting increased PTSD symptomatology, F3, 643 = 77.064, p < 0.001, R2 = 0.261, with age significant at the < 0.05 level and cumulative trauma and logistical barriers significant at the < 0.001 level. Table 6 shows this prediction for stigmatic barriers, F3, 643 = 65.915, p < 0.001, R2 = 0.232, with age significant at the < 0.01 level and cumulative trauma and stigmatic barriers significant at the < 0.001 level. Table 7 shows the prediction for trust barriers, F3, 643 = 58.747, p < 0.001, R2 = 0.211, with age significant at the < 0.01 level and cumulative trauma and trust barriers significant at the < 0.001 level. Finally, a summative model was run, including cumulative trauma and all three barrier types, with the cumulative trauma, logistic barriers, and stigmatic barriers significant predictors in the adjusted model (see Appendix). This model showed all barriers to care variables were significantly associated with PTSD symptomatology, apart from trust barriers to care.
Table 5.
Results of unadjusted and adjusted regression models for logistical barriers to care
| Model | t 5 | p | β | F | df | p | Adjusted R2 |
|---|---|---|---|---|---|---|---|
| Logistical barriers | |||||||
| Unadjusted model | 46.780 | 5, 640 | <0.001 | 0.262 | |||
| Age | −2.048 | 0.041* | −0.072 | ||||
| Gender | −1.225 | 0.221 | −0.042 | ||||
| Relationship status | −0.781 | 0.435 | −0.027 | ||||
| Cumulative trauma | 8.521 | <0.001† | 0.294 | ||||
| Logistical barriers to care | 9.948 | <0.001† | 0.350 | ||||
| Adjusted model | 77.064 | 3, 643 | <0.001 | 0.261 | |||
| Age | −2.171 | 0.030* | −0.076 | ||||
| Cumulative trauma | 8.503 | <0.001† | 0.293 | ||||
| Logistical barriers to care | 9.913 | <0.001† | 0.348 |
* p < 0.05.
† p < 0.001.
Table 7.
Results of unadjusted and adjusted regression models for trust barriers to care
| Model | t 5 | p | β | F | df | p | Adjusted R2 |
|---|---|---|---|---|---|---|---|
| Trust barriers | |||||||
| Unadjusted model | 35.940 | 5, 640 | <0.001 | 0.213 | |||
| Age | −3.076 | 0.002* | −0.110 | ||||
| Gender | −1.186 | 0.236 | −0.042 | ||||
| Relationship status | −1.182 | 0.237 | −0.042 | ||||
| Cumulative trauma | 8.328 | < 0.001† | 0.298 | ||||
| Trust barriers to care | 7.289 | < 0.001† | 0.262 | ||||
| Adjusted model | 58.747 | 3, 643 | <0.001 | 0.211 | |||
| Age | −3.209 | 0.001* | −0.115 | ||||
| Cumulative trauma | 8.328 | < 0.001† | 0.298 | ||||
| Trust barriers to care | 7.188 | < 0.001† | 0.258 |
* p < 0.01.
† p < 0.001.
Table 6.
Results of unadjusted and adjusted regression models for stigmatic barriers to care
| Model | t 5 | p | β | F | df | p | Adjusted R2 |
|---|---|---|---|---|---|---|---|
| Stigmatic barriers | |||||||
| Unadjusted model | 40.487 | 5, 640 | < 0.001 | 0.234 | |||
| Age | −2.495 | 0.013* | −0.089 | ||||
| Gender | −1.646 | 0.100 | −0.058 | ||||
| Relationship status | −0.808 | 0.420 | −0.028 | ||||
| Cumulative trauma | 8.566 | < 0.001† | 0.301 | ||||
| Stigmatic barriers to care | 8.506 | < 0.001† | 0.304 | ||||
| Adjusted model | 65.915 | 3, 643 | < 0.001 | 0.232 | |||
| Age | −2.673 | 0.008† | −0.095 | ||||
| Cumulative trauma | 8.542 | < 0.001† | 0.300 | ||||
| Stigmatic barriers to care | 8.361 | < 0.001† | 0.298 |
* p < 0.01.
† p < 0.001.
Discussion
Military Veterans are known to report high levels of exposure to trauma, and for some this results in PTSD.42–44 When appropriate evidence-based support is received, PTSD symptomatology can be alleviated; however, the path to support is not a simple one, with many barriers impeding help seeking.30,45 The purpose of this study was to examine barriers to care among UK Armed Forces Veterans residing in Northern Ireland, using data from the NIVHWS. The aims were to determine 1) whether barriers to care and cumulative trauma exposure predicted PTSD symptomatology, 2) the extent of the contribution of these barriers to distress, and 3) whether specific types of barriers made a greater or lesser contribution.
The linear relationships between the constructs of interest in this study were significant, showing an increased number of traumatic event exposures, and increased reported barriers to care predicted increased PTSD symptomatology. This is hardly surprising, because PTSD symptoms include intrusive thoughts and re-experiencing (“Treatment may cause me to re-experience it”), avoidance (“If I don’t seek care, I don’t have to think about it”), negative cognition or mood (“I’m too upset, sad, or angry to talk to anyone about it”), and hyperarousal (“I don’t feel safe seeking care”), resulting in a vicious cycle of distress.46 A dose-response relationship between the number of traumatic events an individual is exposed to and PTSD symptom severity is well established in Veteran populations,47–48 as is the relationship between barriers to care and PTSD.25,49
Further to this, in the final summative model including all barrier subscales, it was found that trust was the only domain to exhibit a non-significant influence on PTSD symptomatology. It is suggested that this finding is a result of the profound lack of trust reported by Veterans in Northern Ireland,1,22 including the possibility that NI Veterans with increased trust barriers were unwilling to engage with the study because of those beliefs, rather than this factor being unimportant in predicting PTSD outcomes. There remains a need to granularly explore the role of trust further and in wider Veteran contexts.
To date, the association among cumulative trauma exposure, barriers to care, and PTSD has not been exclusively investigated in a Veteran cohort. Cumulative trauma exposure has, however, been associated with self-stigma and stigmatic beliefs as a barrier to care in other populations and with structural barriers in trauma-expectant occupations.50,51 It bears mention that, although these empirical models considered all traumatic events as equal (and equal to one point), this does not reflect the objective or subjective severity of these events for the individual, nor the time frames and nuances of these events.
A regression model describes the linear relationships between the variables of interest (predictors) and the independent variable and the amount of variance explained by each predictor. In this study, the models tested the extent to which cumulative trauma and barriers to care (overall and by domain) were associated with an increase in PTSD symptoms. All four regression models (unadjusted and adjusted) were significant, showing that cumulative trauma and barriers to care predict PTSD symptomatology. Additionally, although age was not a significant predictor when examining total barriers, younger age did predict PTSD in each of the domain-level models.
Cumulative trauma explained the greatest share of variance in PTSD symptomatology in the total barriers, logistical barriers, stigmatic barriers, and trust barriers models. Total barriers to care explained a small share of the variance, although the contribution of the domain-level barriers was higher. The greatest contribution was seen from the logistical barriers model, followed by the trust barriers and stigmatic barriers models, which aligns with decreased service provision, contextual security issues specific to NI, and, last, the institutional, societal, and self-stigma NI Veterans experience. Most of the sample expressed broad interest in a potential Veterans’ centre located in NI, with mental health support the most frequently endorsed use. Security concerns and risks and transport and other access issues had the highest endorsement for detractors from use, which mirrored the trust and logistical barriers to care outcomes. This demonstrates a genuine need for increased services, primarily for mental health support, one recognized and endorsed by the Veteran population itself.
Impact and implications
Barriers to care predicted increased PTSD symptomatology and, although the contributions of total and discreet barriers to care were not greater than that of cumulative trauma exposure, they were significant from both a statistical and a practical standpoint. Bonnano noted that small effects occur frequently in research, and their nature must be considered when exploring findings.52 Although barriers to care here signify only a small contribution, the actual impact of these barriers on the distress of individuals cannot be overstated, and the direct implications of this study point to the urgent need for increased support for Veterans residing in Northern Ireland. Recommendations from the NIVHWS centred on anti-stigma mental health awareness initiatives (for both the Veteran community and organizations working with Veterans), a centralized resource for facilitating communication and collaboration among charities, statutory organizations, and the Veteran community, and improved resources for local organizations, hubs, and social spaces.1,17,21–22 These are objectively small, incremental steps toward alleviating distress among a larger population, which, in the years since the initial findings of the NIVHWS, has begun to manifest.
Reducing barriers to care in Northern Ireland by addressing security concerns of the Veteran population and facilitating centres and social spaces with improved access to centralized locations would reduce the suffering and distress of individuals in this population. This may also go some way toward reducing the need for Veterans in Northern Ireland to adopt a self-imposed, hidden status. The NIVHWS explored the needs and attitudes of the NI Veteran population regarding a potential Veterans’ centre or hub to provide support resources and reduce barriers to care,22 and work has begun on a Veterans’ residential retreat as a charity endeavour funded by donations.53 Additionally, the recent launch of a new initiative, the Veterans Adviceline for Statutory Professionals, aims to assist professionals in servicing Veteran clients and building trust between the community and the statutory sector.54
Initiatives to educate and reduce the stigma around mental illness and health care in the public have been launched in Northern Ireland and have had a positive impact,23,55 with a new program, You Matter, recently launched to prevent suicide in the Veteran community through a referral program for various social and structured programs and work to destigmatize help seeking.56–57 Support resources diversified across multiple relief projects could positively affect stigma through awareness campaigns and events, reduce logistical accessibility issues, and provide Veterans with bespoke social spaces. Supporting Veterans at a community, grassroots level may be another way to ease security concerns and reduce the need to remain hidden. Recently, the Northern Ireland Veterans’ Places, Pathways, People Programme was launched through a grant from the Covenant Trust and will be coordinating a network of service delivery with an aim of increasing existing services and peer support over 24 months, with service delivery partners facilitating mental health support, peer support pathways, and service integration at multiple levels.58
Strengths and limitations
These findings must be considered alongside the study’s limitations. Of the total cohort (N = 1,329), this study used data from only 657 participants, 49.4% of the original population. The considerable length of the survey may have contributed to attrition, with selective responses potentially skipped because of the complex and unique context surrounding NI military service. This survey recorded self-report data, which carries the inherent risk of social desirability bias,59 especially considering the sensitive subjects raised. As earlier, the quantitative capture of trauma may seem to imply that all traumas are created equal when this is not the case.60–61 The impact of traumatic events on individuals varies independently from the sum scores of discreet events. Similarly, the measurement of barriers to care was standardized with a psychometric scale and does not that imply all barriers have an equal impact on all individuals. This study also did not examine the effects of childhood trauma or trauma severity or delineate between combat and non-combat trauma. Finally, these results should be interpreted with consideration of the fact that cross-sectional data were used, and the causal-mechanistic processes of trauma exposure and help-seeking behaviours on PTSD cannot be definitively established. Further research with more granular assessment is warranted to better understand these processes — for instance, the proposed effect of additive trauma on self-stigmatizing beliefs and structural barriers to care.
An intrinsic problematic aspect of research concerning the population of UK Armed Forces Veterans residing in Northern Ireland is that the size of the population is unknown, which would normally preclude representative comparisons. However, the socio-demographic profile of the NIVHWS sample was found to be broadly similar to the profile of UK Armed Forces Veterans residing in Great Britain in terms of gender, mean age, relationship status, and education level.1 Although findings here do not represent all Veterans residing in Northern Ireland, especially those unwilling to participate because of security concerns or those unable to do so because of poor physical or mental health, the sample may be a fair approximation of the population. As previously discussed, major differences in the availability and administration of Veteran supports and services between Northern Ireland and other nations mean these results likely represent an array of help-seeking barriers that relate to the socio-political nuance of being an armed forces Veteran resident in Northern Ireland.
This study has several strengths. The data used were sourced from the NIVHWS, the first comprehensive research project exploring the NI Veteran community, and subsequent studies using NIVHWS data will function to better explore the population, build a foundational body of literature, and inform future policy. Describing the constellation of variables that contribute to, and have an impact on, the relationship between traumatic events and PTSD distress furthers understanding and awareness of the effects of trauma on individuals and populations alike. Finally, these findings highlight that barriers to care can be both external (lack of transportation, availability) and internal (lack of trust, stigma) but serve the same function as a literal brick wall between the individual and care.
Conclusion
Although it is clear that cumulative exposure to trauma is strongly associated with PTSD symptomatology and distress and that barriers to care also have an impact on distress, the whole of the model is greater than the sum of its parts. Barriers to care, as a whole and when examined by subtype, and cumulative trauma exposure predict PTSD in this population of UK Armed Forces Veterans residing in Northern Ireland, highlighting that, although it is too late to prevent the exposure to trauma for these individuals, concrete steps can be taken to reduce the barriers preventing them from receiving the care they need.
Acknowledgments
Competing Interests
Forces in Mind Trust funded the study in which tese data were collected in 2017. This article is bases on an anlaysis done with those data in 2022; the funder was not involved in the production of this work.
Ethics Approval
Ethics approval was not required for this article.
Informed Consent
N/A
Registry and Registration no. of the Study/Trial
N/A
Animal Studies
N/A
Peer Review
This article has been peer reviewed.
Biographies
Eric Spikol, PhD, is a research fellow at the Stress Trauma and Related Conditions Research Centre at Queen’s University Belfast. An early career researcher, he is an Associate Fellow of Higher Education with an interest in conspiracist ideation, psychosis, trauma’s impact on mental health, and resilience. Spikol has been on the research teams for the UK Veterans Family Study and the PTSD Experimental Treatment Trial.
Catherine Hitch, PhD, comes from a military family and has a heartfelt interest in defence, security, and Veterans. Her PhD focused on the Northern Irish Veteran community in the context of trauma, mental health, alcohol, and help-seeking. She spent five years working to help wounded, injured, and sick Veterans transition to civilian life. Hitch also sits on the Defence and Security Committee of the British Psychological Society.
Martin Robinson, PhD, is currently working as a research fellow at the Stress Trauma and Related Conditions Research Centre at Queen’s University Belfast. His areas of research focus include posttraumatic stress disorder (PTSD) and trauma, complex PTSD, conflict-based trauma, and resilience. Robinson also developed a pilot sexual education program for young incarcerated men, is a Fellow of the Higher Education Academy, and has taught in both the School of Psychology and the School of Nursing and Midwifery at Queen’s.
Emily McGlinchey, PhD, is currently working as a research fellow at the Stress Trauma and Related Conditions Research Centre based in the Psychology Department of Queen’s University Belfast. She is also a British-Psychological-Society-accredited Low-Intensity Cognitive Behaviour Therapy therapistwith more than three years of clinical experience working across a range of both statutory and non-statuary mental health services. McGlinchey is currently involved in a number of high-profile mental health research projects based at Queen’s University Belfast.
Cherie Armour, PhD, is a professor of psychological trauma and mental health, Research Director for the School of Psychology, and the Director of the Research Centre for Stress Trauma and Related Conditions at Queen’s University Belfast. She has held the position of President of the UK Psychological Trauma Society, is an elected board member for the International Society of Traumatic Stress Studies, and is an associate editor for the European Journal of Psychotraumatology.
Appendix
Table A1.
Regression model with all barrier types
| Model | t 5 | p | β | F | df | p | Adjusted R2 |
|---|---|---|---|---|---|---|---|
| All barrier types | |||||||
| Unadjusted model | 38.838 | 7 | < 0.001* | 0.291 | |||
| Age | −1.431 | 0.153 | −0.050 | ||||
| Gender | −1.719 | 0.086 | −0.058 | ||||
| Relationship status | −0.798 | 0.425 | −0.027 | ||||
| Cumulative trauma | 8.168 | <0.001* | 0.278 | ||||
| Logistical barriers to care | 6.576 | <0.001* | 0.256 | ||||
| Stigmatic barriers to care | 3.622 | <0.001* | 0.157 | ||||
| Trust barriers to care | 1.622 | 0.105 | 0.069 | ||||
| Adjusted model | 66.069 | 4 | < 0.001* | 0.286 | |||
| Cumulative trauma | 8.440 | <0.001* | 0.285 | ||||
| Logistical barriers to care | 6.851 | <0.001* | 0.263 | ||||
| Stigmatic barriers to care | 3.788 | <0.001* | 0.163 | ||||
| Trust barriers to care† | 1.530 | 0.127 | 0.065 |
* p < 0.001.
† Item retained in the adjusted model for continuity.
Funding Statement
No funding was received for this article.
References
- 1.Armour C, McGlinchey E, Ross J. The Health and Wellbeing of Armed Forces Veterans in Northern Ireland: The results of a cross-sectional psychological wellbeing survey [Internet]. 2021. [cited 2022 Dec 5] Available from: https://static1.squarespace.com/static/57e159a7cd0f680c065ce66d/t/608adb65ac4e471ee6b462f7/1619712873061/NI+Veterans+Health+%26+Wellbeing+Study+-+Psychological+Wellbeing+Survey+Report.pdf
- 2.Armour C, Robinson M, Ross J. Factor structure of the International Trauma Questionnaire in UK Armed Forces veterans residing in Northern Ireland. Eur J Psychotraumatol. 2021. Jun 17;12(1):1924954. 10.1080/20008198.2021.1924954 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Bunting BP, Ferry FR, Murphy SD, O’Neill SM, Bolton D. Trauma associated with civil conflict and posttraumatic stress disorder: evidence from the Northern Ireland Study of Health and Stress. J Trauma Stress. 2013. Feb;26(1):134–41. 10.1002/jts.21766 [DOI] [PubMed] [Google Scholar]
- 4.Ferry F, Bunting B, Murphy S, O’Neill S, Stein D, Koenen K. Traumatic events and their relative PTSD burden in Northern Ireland: a consideration of the impact of the “Troubles”. Soc Psychiatry Psychiatr Epidemiol. 2014. Mar;49(3):435–46. 10.1007/s00127-013-0757-0 [DOI] [PubMed] [Google Scholar]
- 5.Ross J, Armour C. A latent profile analysis of the dissociative subtype of PTSD in a sample of UK Armed Forces veterans residing in Northern Ireland. Eur J Trauma Diss. 2022;6(3):100267. 10.1016/j.ejtd.2022.100267 [DOI] [Google Scholar]
- 6.Spikol E, Robinson M, McGlinchey E, Ross J, Armour C. Exploring complex-PTSD comorbidity in trauma-exposed Northern Ireland veterans. Eur J Psychotraumatol. 2022;31(1):2046953. 10.1080/20008198.2022.2046953 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Corrigan PW, Druss BG, Perlick DA. The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest. 2014. Oct;15(2):37–70. 10.1177/1529100614531398 [DOI] [PubMed] [Google Scholar]
- 8.Murphy D, Palmer E, Busuttil W. Mental health difficulties and help-seeking beliefs within a sample of female partners of UK veterans diagnosed with post-traumatic stress disorder. J Clin Med. 2016. Aug 1;5(8):68. 10.3390/jcm5080068 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Iversen AC, Greenberg N. Mental health of regular and reserve military veterans. Adv Psychiatr Treat. 2018;15(2):100–6. 10.1192/apt.bp.107.004713 [DOI] [Google Scholar]
- 10.Corrigan PW, Watson AC, Barr L. The self-stigma of mental illness: implications for self-esteem and self-efficacy. J Soc Clin Psychol. 2006;25(8):875–84. 10.1521/jscp.2006.25.8.875 [DOI] [Google Scholar]
- 11.Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. Can J Psychiatry. 2012;57(8):464–9. 10.1177/070674371205700804 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.French C, Rona RJ, Jones M. Screening for physical and psychological illness in the British Armed Forces: II: Barriers to screening — learning from the opinions of service personnel. J Med Screen. 2004;11(3):153–61. 10.1258/0969141041732247 [DOI] [PubMed] [Google Scholar]
- 13.Coleman SJ, Stevelink SAM, Hatch SL, Denny JA, Greenberg N. Stigma-related barriers and facilitators to help seeking for mental health issues in the armed forces: a systematic review and thematic synthesis of qualitative literature. Psychol Med. 2017. Aug;47(11):1880–92 10.1017/s0033291717000356 [DOI] [PubMed] [Google Scholar]
- 14.Salaheddin K, Mason B. Identifying barriers to mental health help-seeking among young adults in the UK: a cross-sectional survey. Br J Gen Pract. 2016. Oct;66(651):e686–92. 10.3399/bjgp16x687313 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Browne KC, Chen JA, Hundt NE, Hudson TJ, Grubbs KM, Fortney JC. Veterans self-reported reasons for non-attendance in psychotherapy for posttraumatic stress disorder. Psychol Serv. 2021. May;18(2):173–85. 10.1037/ser0000375 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Ministry of Defence . Armed Forces mark 50 years since the start of operations in Northern Ireland [Internet]. London: Ministry of Defence; 2019. [cited 2022 Dec 5] Available from: https://www.gov.uk/government/news/armed-forces-mark-50-years-since-the-start-of-operations-in-northern-ireland [Google Scholar]
- 17.Armour C, Waterhouse-Bradley B, Ross J, McLafferty M, Hall M. Public attitudes to the UK armed forces in Northern Ireland [Internet]. London: Forces in Mind Trust; 2018. [cited 2022 Dec 5] Available from: https://www.fim-trust.org/wp-content/uploads/public-attitudes-uk-armed-forces-northern-ireland.pdf [Google Scholar]
- 18.Bradley K. Security situation in Northern Ireland: statement made on 17 December 2018 (HCWS1187) [Internet]. London: UK Parliament; 2018. [cited 2022 Dec 5] Available from: https://www.parliament.uk/business/publications/written-questions-answers-statements/written-statement/Commons/2018-12-17/HCWS1187/ [Google Scholar]
- 19.Heckathorne DD. Respondent-driven sampling: a new approach to the study of hidden populations. Soc Probl. 1997;44(2):174–99. 10.1525/sp.1997.44.2.03x0221m [DOI] [Google Scholar]
- 20.Ministry of Defence . The Armed Forces Covenant [Internet]. London: Ministry of Defence; 2016. [cited 2022 Dec 5] Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/578212/20161215-The-Armed-Forces-Covenant.pdf [Google Scholar]
- 21.Armour C, Waterhouse-Bradley B, Walker E, Ross J. Supporting & serving military veterans in Northern Ireland [Internet]. London: Forces in Mind Trust; 2017. [cited 2022 Dec 5] Available from: https://www.fim-trust.org/wp-content/uploads/supporting-serving-military-veterans-northern-ireland.pdf [Google Scholar]
- 22.Armour C, Walker E, Hall M, Waterhouse-Bradley B, Ross J, McLafferty M. Exploring the need for a veterans’ centre in Northern Ireland [Internet]. London: Forces in Mind Trust; 2018. [cited 2022 Dec 5] Available from: https://s31949.pcdn.co/wp-content/uploads/exploring-need-for-veterans-centre-northern-ireland.pdf [Google Scholar]
- 23.Betts J, Thompson J. Mental health in Northern Ireland: overview, strategies, policies, care pathways, CAMHS and barriers to accessing services [Internet]. Belfast: Northern Ireland Assembly Research and Information Service; 2017. [cited 2022 Dec 5]. NAIR 412–16, paper 08/17. Available from: https://niopa.qub.ac.uk/bitstream/NIOPA/4492/1/0817.pdf [Google Scholar]
- 24.McLafferty M, Lapsley CR, Ennis E, Armour C, Murphy S, Bunting BP, et al. Mental health, behavioural problems and treatment seeking among students commencing university in Northern Ireland. PLoS One. 2017. Dec 13;12(12):e0188785. 10.1371/journal.pone.0188785 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Iversen AC, van Staden L, Hughes JH, Greenberg N, Hotopf M, Rona RJ, et al. The stigma of mental health problems and other barriers to care in the UK Armed Forces. BMC Health Serv Res. 2011;11:31. 10.1186/1472-6963-11-31 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Murphy D, Busuttil W. PTSD, stigma and barriers to help-seeking within the UK Armed Forces. J R Army Med Corps. 2015. Dec;161(4):322–6. 10.1136/jramc-2014-000344 [DOI] [PubMed] [Google Scholar]
- 27.Sharp M-L, Fear NT, Rona RJ, Wessely S, Greenberg N, Jones N, et al. Stigma as a barrier to seeking health care among military personnel with mental health problems. Epidemiol Rev. 2015;37(1):144–62. 10.1093/epirev/mxu012 [DOI] [PubMed] [Google Scholar]
- 28.Murphy D, Ashwick R, Palmer E, Busuttil W. Describing the profile of a population of UK veterans seeking support for mental health difficulties. J Ment Health. 2019. Dec;28(6):654–61. 10.1080/09638237.2017.1385739 [DOI] [PubMed] [Google Scholar]
- 29.Ashwick RL, Murphy D. Exploring the health risks of help-seeking military veterans living in different parts of the UK. J R Army Med Corps. 2018. Feb;164(1):8–14. 10.1136/jramc-2017-000822 [DOI] [PubMed] [Google Scholar]
- 30.Murphy D, Busuttil W. Focusing on the mental health of treatment-seeking veterans. J R Army Med Corps. 2018. Feb;164(1):3–4. 10.1136/jramc-2017-000844 [DOI] [PubMed] [Google Scholar]
- 31.Stevelink S, Jones M, Hull L, Pernet D, MacCrimmon S, Goodwin L, et al. Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: A cohort study. Br J Psychiatry. 2018. Dec;213(6):690–697. 10.1192/bjp.2018.175 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Royal British Legion . The UK ex-service community: a household survey [Internet]. 2014. [cited 2022 Dec 5]. Available from: https://storage.rblcdn.co.uk/sitefinity/docs/default-source/campaigns-policy-and-research/rbl_household_survey_report.pdf?sfvrsn=5bcbae4f_4
- 33.Elhai JD, Miller ME, Ford JD, Biehn TL, Palmieri PA, Frueh BC. Posttraumatic stress disorder in DSM-5: estimates of prevalence and symptom structure in a nonclinical sample of college students. J Anxiety Dis. 2012;26(1):58–64. 10.1016/j.janxdis.2011.08.013 [DOI] [PubMed] [Google Scholar]
- 34.Weathers FW, Blake DD, Schnurr PP, Kaloupek DG, Marx BP, Keane TM. The Life Events Checklist for DSM-5 (LEC-5) [Internet]. Washington, DC: National Center for PTSD; 2013. [cited 2022 Dec 05] Available from: https://www.ptsd.va.gov/professional/assessment/te-measures/life_events_checklist.asp [Google Scholar]
- 35.McGlinchey E, Ross J, Murphy D, Shorter GW, Armour C. Disentangling the symptom-level nuances in comorbid posttraumatic stress disorder and problematic alcohol use in Northern Irish military veterans: a network analysis. J Trauma Stress. 2022. Feb;35(1):32–41. 10.1002/jts.22666 [DOI] [PubMed] [Google Scholar]
- 36.Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5) [Internet]. Washington, DC: National Center for PTSD; 2013. [cited 2022 Dec 5]. Available from: https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp [Google Scholar]
- 37.Murphy D, Ross J, Ashwick R, Armour C, Busutil W. Exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of UK treatment-seeking veterans. Eur J Psychotraumatol. 2017. Nov 13;8(1):1398001. 10.1080/20008198.2017.1398001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med. 2008;358:453–63. 10.1056/nejmoa072972 [DOI] [PubMed] [Google Scholar]
- 39.Britt TW, Greene-Shortridge TM, Brink S, Nguyen QB, Rath J, Cox AL, et al. Perceived stigma and barriers to care for psychological treatment: implications for reactions to stressors in different contexts. J Soc Clin Psychol. 2008;27(4):317–35. 10.1521/jscp.2008.27.4.317 [DOI] [Google Scholar]
- 40.Brown MC, Creel AH, Engel CC, Herrell RK, Hoge CW. Factors associated with interest in receiving help for mental health problems in combat veterans returning from deployment to Iraq. J Nerv Ment Dis. 2011. Oct;199(10):797–801. 10.1097/nmd.0b013e31822fc9bf [DOI] [PubMed] [Google Scholar]
- 41.IBM Corporation . IBM SPSS Statistics for Windows. Armonk, NY: IBM Corporation; 2021. Version 28.0 [Google Scholar]
- 42.Fear NT, Jones M, Murphy D, Hull L, Iversen AC, Coker B, et al. What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study. Lancet. 2010. May 22;375(9728):1783–97. 10.1016/s0140-6736(10)60672-1 [DOI] [PubMed] [Google Scholar]
- 43.Armour C, Contractor A, Elhai JD, Stringer M, Lyle G, Forbes D, et al. Identifying latent profiles of posttraumatic stress and major depression symptoms in Canadian veterans: exploring differences across profiles in health related functioning. Psychiatry Res. 2015. Jul 30;228(1):1–7. 10.1016/j.psychres.2015.03.011 [DOI] [PubMed] [Google Scholar]
- 44.Murphy D, Ross J, Busutil W, Greenberg N, Armour C. A latent profile analysis of PTSD symptoms among UK treatment seeking veterans. Eur J Psychotraumatol. 2019. Jan 21;10(1):1558706. 10.1080/20008198.2018.1558706 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Mellotte E, Murphy D, Rafferty L, Greenberg N. Pathways into mental health care for UK veterans: a qualitative study. Eur J Psychotraumatol. 2017. Oct 25;8(1):1389207. 10.1080/20008198.2017.1389207 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Tarrier N, Pilgrim H, Sommerfield C, Faragher B, Reynolds M, Graham E, et al. A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. J Consult Psychol. 1999;67(1):13–8. 10.1037/0022-006x.67.1.13 [DOI] [PubMed] [Google Scholar]
- 47.Jakob J, Lamp K, Rauch S, Smith E, Buchholz KR. The impact of trauma type or number of traumatic events on PTSD diagnosis and symptom severity in treatment seeking veterans. J Nerv Ment Dis. 2017. Feb;205(2):83–86. 10.1097/nmd.0000000000000581 [DOI] [PubMed] [Google Scholar]
- 48.Lehavot K, Katon JG, Chen JA, Fortney JC, Simpson TL. Post-traumatic stress disorder by gender and veteran status. Am J Prev Med. 2018. Jan;54(1):e1–e9. 10.1016/j.amepre.2019.08.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Williamson V, Greenberg N, Stevelink SAM. Perceived stigma and barriers to care in UK Armed Forces personnel and veterans with and without probable mental disorders. BMC Psychol. 2019;7:75. 10.1186/s40359-019-0351-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Kennedy AC, Bybee D, Greeson MR. Examining cumulative victimization, community violence exposure, and stigma as contributors to PTSD symptoms among high-risk young women. Am J Orthopsychiatry. 2014. May;84(3):284–94. 10.1037/ort0000001 [DOI] [PubMed] [Google Scholar]
- 51.Stanley IH, Boffa JW, Hom MA, Kimbrel NA, Joiner TE. Differences in psychiatric symptoms and barriers to mental health care between volunteer and career firefighters. Psychiatry Res. 2017. Jan;247:236–42. 10.1016/j.psychres.2016.11.037 [DOI] [PubMed] [Google Scholar]
- 52.Bonnano GA. The resilience paradox. Eur J Psychotraumatol. 2021. Jun 30;12(1):1942642. 10.1080/20008198.2021.1942642 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 53.Lynch C. Work underway on new veteran’s centre in North Down [Internet]. BelfastLive; 2022. Mar 9 [cited 2022 Dec 05] Available from: https://www.belfastlive.co.uk/news/northern-ireland/work-underway-new-veterans-centre-23220531 [Google Scholar]
- 54.Northern Ireland Veterans Support Office . Veterans’ Adviceline for Statutory Professionals (VASP) [Internet]. Belfast: Northern Ireland Veterans Support Office; 2022. [cited 2022 Dec 5]. Available from: https://nivso.org.uk/programmes/1/veterans-adviceline-for-statutory-professionals-vasp [Google Scholar]
- 55.Health and Social Care Northern Ireland . Tackling mental health stigma and discrimination [Internet]. Belfast: Public Health Office; 2016. [cited 2022 Dec 5]. Available from: https://www.publichealth.hscni.net/news/tackling-mental-health-stigma-and-discrimination [Google Scholar]
- 56.Inspire Wellbeing . New You Matter veterans’ project aims to support mental health and prevent suicide [Internet]. Belfast: Inspire Wellbeing; 2022. [cited 2022 Dec 5]. Available from: https://www.inspirewellbeing.org/new-you-matter-veterans-project-aims-to-support-mental-health-and-prevent-suicide/ [Google Scholar]
- 57.Northern Ireland Veterans Commissioner’s Office . “You Matter” — NI Veterans suicide prevention project launched [Internet]. Belfast: Northern Ireland Veterans Commissioner’s Office; 2022. [cited 2022 Dec 5] Available from: https://www.nivco.co.uk/you-matter-ni-veterans-suicide-prevention-project-launched [Google Scholar]
- 58.Northern Ireland Veterans Support Office . Northern Ireland Veterans’ Places, Pathways, People Programme [Internet]. Belfast: Northern Ireland Veterans Support Office; 2022. [cited 2022 Dec 5] Available from: https://nivso.org.uk/programmes/3/northern-ireland-veterans-places-pathways-people-programme [Google Scholar]
- 59.van de Mortel. Faking it: social desirability response bias in self-report research. Aus J Adv Nurs, 2008;25(4):40–8 [Google Scholar]
- 60.Briggs EC, Amaya-Jackson L, Putnam KT, Putnam FW. All adverse childhood experiences are not equal: the contribution of synergy to adverse childhood experience scores. Am Psycho l. 2021. Feb–Mar;76(2):243–52. 10.1037/amp0000768 [DOI] [PubMed] [Google Scholar]
- 61.Prost SG, McDonald A, Plassmeyer M, Middleton J, Golder S. Not all traumas are equal: post-traumatic stress and quality of life among women in prison. Women Crim Justice. 2021;32(6):502–19. 10.1080/08974454.2020.1871160. [DOI] [Google Scholar]