If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Correspondence to: Lisa Marie Sternke, PhD, MSN, RN, 109 Bee Street, Charleston, SC 29401. Phone: (843) 367-5472; fax: (843) 556-7759.
Affiliations
VA Nursing Academy, Department of Veterans Affairs, Ralph H. Johnson VA Medical Center, Charleston, South CarolinaCollege of Nursing, Medical University of South Carolina
To examine combat exposure measurement instruments utilized since the Vietnam War, determine how these instruments were developed and psychometrically tested, and if they are appropriate for use with women veterans exposed to combat.
Methods
A literature search for articles concerning combat exposure instruments, their development, and their psychometric properties in relation to women was conducted in several electronic databases. Limited MeSH subject headings required keyword searches with terms such as combat stress, war trauma, and deployment stressors. Instruments were selected for analysis based on their inclusion of combat and combat-related traumatic event measures.
Results
Eight instruments were retained for critical appraisal. The majority of instruments were developed and validated based on male veterans’ combat experiences from the Vietnam War through the Gulf War. Located instruments explained their methodological development and indicated the type of exposure being measured. Reliability measures for the majority were acceptable, and validity was established to varying degrees and with different methods. Limitations of all instruments included retrospective self-reporting, potential recall error, and the inability to validate individual exposure objectively.
Conclusion
Women veterans are substantially under-represented in the development and psychometric testing of combat exposure instruments, indicating a male gender bias in most combat measures. Only two instruments utilized women veterans in their validation samples, and six instruments used gender-neutral terminology. Instruments developed and validated with male veterans for specific military conflicts may not reflect the combat experiences of women.
Stauffer, S. A., Lumsdaine, A. A., Lumsdaine, M. H., Williams, R. M., Smith, M. B., Janis, J. L. K., Star, S. A., & Cottrell. L. S. (1949). The American Soldier (Vol. III). Combat and its Aftermath. Princeton, NJ: Princeton University Press.
defined combat exposure as “a set of experiences in which the individual came into direct contact with the enemy, in the form of fighting by firing weapons and taking the life of an enemy Soldier; had his life threatened by hostile action; and suffered the concomitant physical and moral discomfort” (in
, p. 67). This definition’s connection between combat exposure and negative physical and mental health outcomes has since been well established; however, its significance lies in its identification of combat exposure as a specifically male experience. Emerging research indicates more women veterans are being exposed to combat owing to its changed nature and the assignment of women to combat support positions; therefore, accurately measuring women veterans’ combat exposure levels would seem crucial, yet research on actual measures of combat exposure in relation to women is sparse (
); thus, the validity and reliability of combat exposure measures when used with women must be examined. Continually measuring combat exposure from a male-dominated perspective creates a gender bias which could systematically produce erroneous research results (
). The theory of gender and risk perception provides an excellent framework to examine combat exposure from a gender perspective because it proposes there are differences in the gender perception of risks, these differences are influenced by the meaning attributed to a perceived risk, and acknowledges that what seems to be the same risk on a questionnaire may be interpreted differently by men and women (
Research also indicates the greater the level of combat violence experienced, the greater the odds for negative psychological outcomes—a “dose–response” relationship (
The purpose of this study was to analyze the initial psychometric properties of combat exposure measurement instruments utilized since the Vietnam War. Understanding combat exposure from a gender perspective may provide more insight into its effects on both women and men, and potentially lead to the development of gender-specific instruments and interventions. The following research questions are addressed in this analysis: 1) What instruments are available for measuring combat exposure and what aspects of exposure do they measure? 2) What are the psychometric properties of these instruments? 3) With what samples were instrument psychometric properties determined? and 4) What gaps exist in the research regarding combat exposure measurement instruments and women veterans?
Instrument evaluation consisted of determining the following instrument properties: Was the instrument based on a conceptual definition of combat? Was its development methodologically explained? Was it developed with both men and women? Did it exhibit gender neutrality (i.e., was instrument wording gender specific)? Did it measure the frequency, severity, and duration of combat exposure? What types of combat exposure did it measure? Did it show acceptable reliability (internal consistency and test-retest) and validity (construct, content, and criterion)?
Background and Significance
Deployments to Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) have steadily increased (
Compounding issues in combat exposure measurement is the increased number of women in service, from 2% during the Vietnam Era to nearly 15% as of September 2010 (
). Combat techniques are more sophisticated and combat occurs in more complex and crowded urban settings, making traditional lines of combat less distinct (
Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: Prospective US military cohort study.
). PTSD is defined by the Diagnostic and Statistical Manual of Mental Disorders-IV as a psychological and/or physical reaction (lasting >1 month) to negative and/or adverse events characterized by intense fear or threat, intrusive recollection of the exposure, avoidance of stimuli associated with the exposure, emotional numbing, hyperarousal, and an impairment in functioning (
Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care.
Journal of Nervous and Mental Disease.2008; 196: 425-428
Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: Prospective US military cohort study.
). Severely injured combat veterans have a greater risk for developing PTSD than those who have noncombat injuries, and have significantly greater risk for any mental health diagnosis (
). Women veterans exposed to combat are nearly two times more likely to develop disordered eating and more than twice as likely to experience extreme weight loss as women without combat exposure (
). These findings support examining the need for a gender-appropriate measure of combat exposure which accurately predicts its consequences.
Methods
An initial literature search utilizing the keywords combat and exposure was conducted in several computerized databases, including the Cumulative Index to Nursing and Allied Health Literature, OVID: Medline, PsychINFO, and PubMed, resulting in 2,457 articles (limits 1980–2009). Another search combining the original keywords into combat exposure was conducted resulting in 766 articles. A third search combining the keywords of combat exposure with measurement, instrument, scale, and psychometrics resulted in 57 articles. Review of these articles revealed additional aspects of combat exposure such as military trauma, combat trauma, combat stress, war-zone trauma, war-zone stress, wartime trauma, atrocities, deployment stressors, and abusive violence. Searches were conducted using different combinations of these keywords to locate instruments which had some type of combat exposure measure, as well as searches for specific instruments mentioned in the articles, resulting in 72 articles for examination. After exclusion of articles with no validated combat exposure measurement instrument and those containing instruments measuring combat exposure in conjunction with PTSD, nine instruments remained for examination. Instruments were selected for analysis based on their inclusion of combat exposure measures and combat-related traumatic event measures. One instrument was excluded because it was used only once and subsequently destroyed by Hurricane Katrina. Eight instruments were retained for critical analysis (Figure 1; Table 1).
Defined as exposure to traditional combat experiences such as firing a weapon or being fired on, going on patrols or missions, witnessing the death or injury of others, and so on.
Defined as noncombat events involving nonsanctioned or excessive violence toward combatants or civilians with no risk for injury or physical harm to the veteran in which victims could not avoid or prevent personal injury.
∗ Defined as exposure to traditional combat experiences such as firing a weapon or being fired on, going on patrols or missions, witnessing the death or injury of others, and so on.
† Defined as witnessing or participating in random violence against others not required for self-defense.
‡ Defined as psychosocial war-related stressors possibly unique to women.
§ Defined as noncombat events involving nonsanctioned or excessive violence toward combatants or civilians with no risk for injury or physical harm to the veteran in which victims could not avoid or prevent personal injury.
The initial psychometric properties of the analyzed instruments are reported in Table 2 in date of development order. The following is an explanation of each instrument, what it measures, its sample(s) and sampling method, its psychometric results, and its listed limitations in development and use. It is important to note only the initial psychometric results after instrument development are reported.
82 male Vietnam veterans (34 clinical; 48 nonclinical)
0.98
Not measured
Not measured
Established by professional review (20)
Significant score difference between clinical and nonclinical groups
Laufer Combat Scale—Revised
350 male Vietnam veterans
Not available
Not available
r = 0.55 correlation with killing another; r = 0.43 correlation with abusive violence
Not available
Not available
Combat Exposure Scale
Phase 2: 362 male Vietnam Era veterans Phase 3: 39 Vietnam Theater veterans Phase 4: 62 Vietnam combat veterans (30 with PTSD, 32 with no psych history)
Phase 2: 0.85 Item-remainder: 0.75
Phase 3: 0.97 (1 week) (p < .0001)
Phase 1: Principal components analysis/factor loadings
Phase 1: Established through factor analysis and interview of veterans by mental health professionals
Phase 3: High correlation with M-PTSD (0.43; p = .01; no psychiatric history group) Phase 3: Between groups mean difference (PTSD vs. non-PTSD; 2.98; p < .005)
Abusive Violence Scale
60 Vietnam veterans from the Midwest (no delineation of male/female)
0.81
Not measured
0.91 correlation with CES
Established through factor analysis
0.58 correlation with self-report of combat intensity
Combat Exposure Index
68 male twin Vietnam veterans
0.84
0.91 (1 week)
Not stated
Questions derived from previous combat exposure studies
Highly correlated with service medal receipt
Women’s Wartime Stressor Scale
147 Vietnam Theater veterans, 32 Era veterans, and 23 Theater civilians (all female)
0.89
0.91 (p < .001) 12–18 months
Previous veteran interview, literature review, previous instrument questions
Established through factor analysis
0.43 correlation with M-PTSD (p < .001) 0.35 correlation with MMPI-PTSD subscale (p < .001) 0.39 correlation with SCL-90-R General Severity Index (p < .001)
High with CES: Observed = 0.38 (p < .05) Participated = 0.34, ns
Consensus of mental health professionals and Vietnam combat veterans
0.45 correlation with M-PTSD (p < .05)
Combat Experiences Scale
Phase 2: 357 Gulf War veterans (277 male and 80 female) Phase 3: 317 Gulf War veterans (234 male and 83 female) Phase 4: 357 Gulf War veterans (271 male and 86 female)
Phase 2: 0.85 Phase 3: 0.85
Not measured
Literature review Content analysis by 5 experts Review by focus groups
Literature review Content analysis by 5 experts Review by veteran focus groups
0.26 correlation with neurocognitive deficits (author developed scale) 0.32 correlation with PTSD Checklist
) is a 66-item instrument with a 12-item subsection measuring traditional combat exposure. It is a Likert instrument with responses indicating severity of combat experiences as never, rarely, occasionally, often, and very often. The questionnaire was administered to a purposive, convenience sample of 82 Vietnam veterans, 34 clinical (help-seeking) and 48 non-clinical (non–help-seeking). The gender of the sample was all male (Stretch, personal correspondence, December 4, 2009). Comparison of the groups’ responses resulted in a reliability coefficient of 0.98. Content validity was established by members of the Consortium on Veteran Studies review of survey questions. Criterion validity was established by the significant difference in responses between the two groups. Researchers concluded the questionnaire was appropriate for use not only with Vietnam theater combat veterans, but also with civilians if the wording were modified for specific traumatic events. Limitations of this questionnaire were not discussed.
) is a 10-item instrument measuring traditional combat exposure. It is a dichotomous (yes/no) instrument containing six questions weighted singly and four questions weighted doubly, with combat exposure results indicated as low (1–4), moderate (5–9), or heavy (10–14). The scale was administered to a stratified probability sample of 350 male Vietnam veterans via telephone interview, along with a single question regarding whether or not the participant had killed another and a set of open-ended questions regarding abusive violence. Reliability for the scale was not indicated. The scale was highly correlated with a participant having killed an enemy combatant (r = 0.55), and moderately correlated with an abusive violence indicator (r = 0.43). Limitations of this scale were not discussed.
) is a seven-item instrument evaluating traditional combat exposure. It is a mixed response questionnaire with each question weighted according to experience severity, frequency, and duration. Combat exposure level is then calculated and defined as light, light-moderate, moderate, moderate-heavy, or heavy. The scale was first validated with a convenience sample of 362 help-seeking male Vietnam veterans, showing an internal consistency of 0.85. With a second sample of 39 male, non–help-seeking Vietnam veterans employed by the Veteran’s Administration (VA), the scale showed test-retest reliability of 0.97 at one week (p < .0001). A third sample of 62 Vietnam veterans (30 with PTSD and 32 with no psychiatric history) yielded a significant between-group mean difference for those with PTSD (2.98; p < .005.) and the Mississippi Scale for Combat-Related PTSD (M-PTSD; 0.43; p = .01, no psychiatric history group). Researchers concluded the scale was appropriate for further use, citing its retrospective self-report nature and the potential for adjustment problem influence on scores as limitations.
) is a five-item instrument measuring abusive violence involvement of veterans in a combat environment. It is a dichotomous (yes/no) instrument to determine veteran witnessing of and/or participation in abusive violence, defined by
, p. 1258). The scale was administered to a sample of 60 Midwestern Vietnam veterans (gender not delineated, sampling method not listed), along with the Combat Exposure Scale and one question assessing personal perception of intensity of combat (none, light, moderate, or heavy). The internal consistency of the scale was 0.81. Test–retest reliability was not measured. The scale showed high construct validity; it was significantly correlated with both the Combat Exposure Scale (r = 0.64; p < .001) and the personal question response regarding combat intensity level (0.58; p < .001). Concurrent validity could not be established because no other instruments measuring abusive violence existed. Researchers concluded the scale was a promising, reliable, and valid instrument for measuring abusive violence. The cited limitation was the lack of test–retesting.
) is an 18-item instrument measuring traditional combat exposure based on specific Vietnam combat experiences and awarded service medals. It was administered to 192 male twin Vietnam veterans from the Vietnam Twin Registry who responded to a mailed questionnaire. It measures 18 combat-related experiences from no combat to high levels of combat. Its internal consistency was 0.84. Nine out of the 18 question responses had agreement rates of greater than 90%. It was highly correlated with the receipt of service medals. Researchers concluded this was a reliable and valid index, with the possible limitations of recall error and self-report.
) was developed specifically for women to address wartime stressors associated with the Vietnam War. A convenience sample of 147 Vietnam Theater veterans (women who served in Vietnam or its surrounding countries), 32 Vietnam Era veterans (women who served in a military capacity from 1964 to 1973 but were not in Vietnam), and 23 Theater civilians (those who were in Vietnam but not military) were administered the 4-point Likert scale. Participants also completed the M-PTSD, the Minnesota Multiphasic Personality Inventory (MMPI PTSD) subscale, and the Symptom Checklist-90-Revised (SCL-90-R; a measure of psychological symptoms and psychopathology). The scale showed an internal consistency of 0.89, and a test–retest reliability of 0.91 (p < .001) at a 12- to 18-month interval. Criterion validity was established by significant correlations with the M-PTSD (r = 0.43; p < .001), the MMPI PTSD subscale (r = 0.35; p < .001), and the SCL-90-R (r = 0.39; p < .001). Author-listed limitations of this instrument were its use of an all-female, all–Vietnam era sample, meaning there was no measure of how examined stressors may have been perceived by men, and also the low response rate of non-Theater women for comparison with Theater women. A psychometric evaluation of this measure with men has not been completed.
) was developed to assess wartime atrocity experiences. Its sample consisted of 125 male, help-seeking veterans at a veteran medical center in the Northeast (sampling method unidentified). It showed high internal consistency (observed atrocities 0.92; participated in atrocities 0.95), as well as test–retest reliability (observed atrocities, 0.83; participated in atrocities, 0.87). The correlation of this scale with the Combat Exposure Scale and observing atrocities was 0.38 (p < .05) and 0.34 (not significant) for participants in atrocities. It had high convergent and content validity, but further assessment of construct validity was suggested. Cited limitations of this instrument included possible participant reluctance to admit participating in atrocities and a sample of only help-seeking veterans.
) is part of the Deployment Risk and Resilience Inventory, a 201-item questionnaire developed to assess risk and resilience factors associated with deployment in a war zone. It contains 15 items specifically addressing combat exposure. This instrument was psychometrically tested in four phases. Phase 1 consisted of a literature review, construct definition, focus groups with veterans (male and female), and resultant item generation. Content analysis by experts resulted in final item determination. Phase 2 consisted of a telephone survey with a stratified random sample of 357 Gulf War veterans (75% male and 25% female). The internal consistency of the combat exposure section was 0.85. Phase 3 consisted of a mailed survey to a stratified random sample of 317 Gulf War veterans (74% male and 26% female from the Phase 2 sample), and the internal consistency was again 0.85. Phase 4 utilized a stratified sample of 357 Gulf War veterans (74% male and 26% female) and focused on associations between all instrument subscales. Construct/content validity for this instrument was established through literature review, expert and veteran review of items, focus groups, and subsequent phase testing. No limitations regarding the combat measurement section of this measure are listed.
Discussion
This review identified eight instruments aiming to measure combat exposure with varying degrees of conceptual grounding, methodology, reliability, and validity. Discussion of the development of a measurement instrument should include an explanation of both the conceptual framework on which it is based and its methodological construction processes (
). A conceptual basis is integral to instrument validity because it defines the construct under study and provides a set of underlying procedures to assist in determining the constructs of that concept. The results of this analysis (Table 3) indicate the conceptual aspects of instrument development have largely been unstated, addressed indirectly in the Laufer Combat Scale and the Women’s Wartime Stressor Scale (by definition), and directly in only the Combat Experiences Scale (risk and resilience constructs). Instrument development also requires specification of how items were determined, which were retained, and how they were measured and scored (
). Analysis revealed the constructs of combat exposure in most instruments were not defined and principally delineated by the instruments themselves. All instrument studies contained methodological explanations for instrument development and scoring. Further, the psychometric properties of an instrument should include representations of both its validity and reliability, validity being an instrument’s ability to measure what it was created to measure, and reliability being the consistency of an instrument in that measurement (
Instrument characteristics were very similar. All instruments indicated the type of exposure being measured and whether the exposure was direct (being personally exposed to combat) or indirect (witnessing others being exposed to combat). The most common elements measured among all studies were exposure to death and dying and witnessing wounding or injury. More than half of the instruments measured the frequency of exposure, but only the Vietnam Veterans Questionnaire and Combat Exposure Scale measured the severity of exposure, and only the Combat Exposure Scale measured duration of exposure. The scales reviewed only partially measure the domains of frequency, severity, and duration, which have been shown to influence individual health issues. Further, only six of the instruments used gender-neutral wording: The Vietnam Veterans Questionnaire was geared toward men and the Women’s Wartime Stressor Scale was geared toward women. Women veterans’ increased risk for exposure to combat suggests instruments measuring this exposure should not be gender specific.
Reliability measures for the majority of instruments were acceptable. The internal consistency of all instruments except the Laufer Combat Scale (not available) was moderate to high, ranging from 0.81 to 0.95. There is some disagreement in the literature regarding acceptable internal consistency values; however, for new instruments an internal consistency value of 0.70 is considered adequate (
). All instruments except for the Laufer Combat Scale (not available) surpass this recommendation. Test–retest reliability, measured in only four studies, ranged from 0.72 to 0.97, with a score over 0.70 being regarded as acceptable (
Acceptable validity of the instruments was established in all, but to varying degrees and with different methods. Four of the instruments were validated against measures of PTSD, although most did not claim to be predictive of PTSD, which is especially interesting because none of the instruments claim any kind of sensitivity or specificity in the diagnosis of PTSD. The majority of the instruments established instrument construct, content, or criterion validity (i.e., determination of a conceptual basis for the instrument, systematic evaluation of instrument content with a representative sample, and comparison with another valid instrument measuring the same construct). This validation was completed through the use of professionals in the psychological field and military veterans reviewing items, factor analysis and item correlation, focus groups of veterans, correlation with other measures of combat exposure, literature review, and the use of items from previously established instruments.
Limitations of all instrument validations were their reliance on self-report of veterans, although few list this as a limitation. Self-report measures can be skewed positively or negatively by having a mental health diagnosis, recall error, the inherently subjective nature of instrument response, and the researcher’s inability to validate the self-reports (
). The majority of validation studies relied on retrospective reports of veterans many years after their tours of duty and exposures to combat; therefore, timing and recall error could be limitations of the validations. Although there is some evidence indicating reports of blast exposure in OEF/OIF more than double one year post-deployment (
Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in National Guard Soldiers deployed to Iraq.
), other research indicates combat exposure recall may be stable. Vietnam veteran retrospective reports of combat exposure level were found to be closely in agreement (96.5% in a low exposure group, and 72.1% in a high exposure group) with a military history measure more than 10 years after the war (
). Specifically, initial validation of instruments should be conducted with heterogeneous samples, including women, to obtain more accurate interpretations of the instrument’s psychometric properties (
). Of the eight instruments analyzed, only two (the Women’s Wartime Stressor Scale and the Combat Experiences Scale) contained women veterans in their samples and only the Combat Experiences Scale validation study contained a number of female participants equaling (actually exceeding) the current gender distribution of the military. One study (the Abusive Violence Scale) utilized a sample including participants from only one geographical area, and all studies contained samples of veterans who participated in a specific conflict (either Vietnam or the Persian Gulf War).
Conclusion
The glaring gap in combat exposure instrumentation is the underrepresentation of women veterans in the validation of instruments, thereby indicating a measurement gender bias at least in the initial assessment of these instruments. The majority of instruments were initially validated based on the combat experiences of male veterans who served during the Vietnam War through the Gulf War, with the exception of the Women’s Wartime Stressor Scale and the Combat Experiences Scale, although many were subsequently used in mixed-gender samples. Measurement instruments developed and validated with previous generations of male veterans may not reflect the combat experiences faced by women veterans or more recent veterans of either gender. Men and women may have different reactions to traumatic experiences (
). For example, there are gender-specific risk factors making women veterans more susceptible to the psychological effects of witnessing or experiencing violence, such as prior trauma and differing physiological and emotional response patterns (
), which could contribute to combat stress reactions. Emerging research suggests a biological stress hormone link making some women more susceptible to a stress reaction from severe trauma (
Further gender-specific research on combat exposure perceptions and measurement is essential; it may lead to both an improved understanding of women’s combat experiences and gender-specific interventions aimed at improving their mental health. This research is in line with goals set forth by the VA Women’s Health Research Agenda (
), which are to research gender-specific military exposures, emotional/psychiatric health, and stress-related behavioral health. Findings from this review should inform policymakers of the need to reevaluate commonly utilized and male normed combat exposure measurement instruments with women veterans based on both the changed military gender demographic and current VA policies specifically aimed at improving the health of women veterans.
Limitations of this analysis include the difficulty in locating older combat exposure measurement instruments, as well as the difficulty of comparing instruments which measure different constructs of combat exposure. Many studies examined combat exposure but did not utilize a validated instrument for its measurement, or constructed one specifically for their study based on other exposure instruments without reporting any psychometric results. These studies were excluded based on their sheer number and the scope of this analysis, but may provide valuable information in further exploration of combat exposure instruments.
Finally, combat exposure instruments are not static in nature and in some cases have been adapted over time. For example, the Laufer Combat Scale was initially developed with a sample of male Vietnam veterans, then later adapted for use with a mixed-gender sample of Gulf War veterans by adding several conflict-specific combat questions (
). The Combat Exposure Index was initially validated with a sample of male Vietnam veterans, then modified in several studies with mixed-gender samples of veterans from varying conflicts (
). These subsequent uses of instruments may affect the stability of this review. Although measured core combat constructs probably do not change, it is likely instrument psychometric properties will, highlighting the importance of tracking measurement instrument usage and adaptation over time. Implications of this review include the need for future research on the use of established instruments with veterans from different combat eras and between genders, as well as the validity of using male-oriented instruments in the women veteran population.
Acknowledgments
The author thanks Dr. Charlene A. Pope and the manuscript reviewers for their invaluable editorial contributions.
References
Alvarez L.
Women at arms: G.I. Jane breaks the combat barrier.
New York Times.2009; (Available:) (Accessed April 18, 2011)
Posttraumatic stress and its relationship to physical health functioning in a sample of Iraq and Afghanistan War veterans seeking postdeployment VA health care.
Journal of Nervous and Mental Disease.2008; 196: 425-428
Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: Prospective US military cohort study.
Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in National Guard Soldiers deployed to Iraq.
Stauffer, S. A., Lumsdaine, A. A., Lumsdaine, M. H., Williams, R. M., Smith, M. B., Janis, J. L. K., Star, S. A., & Cottrell. L. S. (1949). The American Soldier (Vol. III). Combat and its Aftermath. Princeton, NJ: Princeton University Press.
Lisa Marie Sternke, PhD, MSN, RN, is a researcher and Nurse Faculty with the VA Nursing Academy at Charleston VAMC and Clinical Instructor at the Medical University of South Carolina College of Nursing whose research interest is combat exposure measurement in women veterans.
Article info
Publication history
Accepted:
April 20,
2011
Received in revised form:
April 19,
2011
Received:
November 19,
2010
Footnotes
This study by an investigator supported by the Veterans Affairs Nursing Academy (or VANA) was funded in whole or in part by Federal Funds from the Department of Veterans Affairs and administered through Veterans Health Administration Office of Academic Affiliations. The opinions expressed herein do not necessarily reflect the views of the Department of Veterans Affairs or its affiliates, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.
00105-8&id=gr1.jpg){kind=link}