Public Health Nursing 0737-1209/© 2014 Wiley Periodicals, Inc. doi: 10.1111/phn.12118
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Experiences of Wives of Iranian War Veterans with Posttraumatic Stress Disorder Regarding Social Relationships Seyyed A. Vagharseyyedin, B.Sc., M.Sc., Ph.D. Faculty of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran Correspondence to: Seyyed A. Vagharseyyedin, Nursing and Midwifery College, Birjand University of Medical Sciences, Ayatollah Ghaffari Avenue, Birjand 97175-379, Iran. E-mail: [email protected]
ABSTRACT Objective: The aim of this study was to describe the lived experiences of wives of Iranian veterans with PTSD concerning their social relationships. Design and Sample: A qualitative design with a qualitative content analysis approach was used for data collection and analysis of wives experiences. Fourteen wives of war veterans with PTSD participated in this study. Measures: Qualitative data were collected using in-depth semistructured interviews. Results: Two themes emerged from the analysis: (1) Dynamic interaction between the limited social world and the spiritual world, and (2) Seeking a sensitive and assistive atmosphere. Disruption of social activities, necessity of the publics realistic perception of families problems, and the need for additional social support were among the most emphasized points made by participants. Conclusions: Findings of the study can provide some direction for priority setting of problems and designing interventions to improve social lives of wives of Iranian patients diagnosed with PTSD. Further, the findings provide a base for comparing similar possible studies conducted in other societies with the Iranian society. Key words: content analysis, Iran, PTSD, social relationships, wives of war veterans.
Posttraumatic stress disorder (PTSD) is a mental health problem that can occur after witnessing or directly experiencing life-threatening events such as natural disasters, terrorist incidents, serious accidents, or combat. People who suffer from PTSD often experience symptoms such as difficulty in sleeping, nightmares, uncontrollable thoughts, and depression (Blum et al., 2012; Lamprecht & Sack, 2002). Approximately, one third of patients diagnosed with PTSD progress to chronic and unremitting disease (Blum et al., 2012) that may significantly impair their ability to function normally in social life (Iribarren, Prolo, Neagos, & Chiappelli, 2005). High rates of PTSD in war veterans have been found throughout history (Shalev, 2002). Unfortunately, the prevalence of PTSD among Iranian war veterans is unknown. However, considering the
8-year-long Iran-Iraq war, it can be inferred that there are likely to be numerous war veterans suffering from this disorder in Iran. Previous research shows that PTSD, as a chronic disease, not only affects the quality of life of war veterans but also creates a huge burden on their caregivers and families (Devilly, 2002). The process of caring for someone who has been traumatized makes the caregiver vulnerable to impaired social relations, burnout, depression, suicidal ideation, and psychiatric problems such as high levels of subjective stress (Klaric et al., 2010; MangunoMire et al., 2007). In Iran, the majority of male war veterans with PTSD live at home with the assistance of their wives. Given the cultural background of Iranian society, the wives are expected to provide all the support that veterans with PTSD need. In fact, after PTSD
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develops in husbands, their wives often enter into new roles without formal education, and thus become susceptible to the abovementioned problems. As a population at risk in terms of psychosocial problems, wives of patients with PTSD should be targeted by public health nursing services. Public health nurses at the generalist or specialist level empower individuals and others to improve their own health and well-being, and to minimize the effects of specific health conditions (Willis, 2009). In view of the frequent contact of these nurses with families caring for a member with PTSD in a real-world context, they enjoy a good chance to collect the valid data to guide interventions to promote the well-being of this population. Obviously, such an opportunity is more available to the nurses in countries where there is an advanced public health nursing system. These interventions are expected to be designed within an evidence-based practice framework. Evidence-based practice provides nurses with a method to use critically appraised and scientifically proven evidence for delivering effective health care to a specific population (Majid et al., 2011). Certainly, implementing evidence-based practice is possible only when enough research evidence is available. Nevertheless, a review of the related literature to PTSD conducted in Iran demonstrates that most research on PTSD has focused on the veterans, and what is lacking is information regarding the experiences of wives of the Iran-Iraq war veterans with PTSD. The wives of Iranian war veterans with PTSD, especially unemployed ones, spend more time at home and possibly may have limited social relationships. This can in addition aggravate their psychological problems (Dekel, Goldblatt, Keider, Solomon, & Polliack, 2005). Social relationships as a source of support are also considered as mechanisms for enhancing population health and well-being. Over the past years, several studies have provided consistent evidence linking a low quantity or quality of social relationships with a host of conditions, including development and progression of cardiovascular disease, high blood pressure, and dysregulation of immune function (Bell, Thorpe, & Laveist, 2010; Everson-Rose & Lewis, 2005). Social isolation, social integration, social support, and social networks have been described
as features of social relationships (Umberson & Montez, 2010). Social isolation refers to the relative absence of social relationships. Social integration is the overall level of involvement with formal and informal social relationships. Social networks include the web of social relationships surrounding an individual. Social support generally refers to a more focal set of relationships such as an individual’s friends and family (Gapen et al., 2011; Smith & Christakis, 2008). Since nurses, especially public health nurses, have a commitment to their community for the prevention of illnesses and provision of holistic care, they must recognize and address concerns of wives of patients with PTSD. During assessment of health status of these clients, the environmental, psychosocial, and cultural factors that may influence the potential to achieve or maintain health should be viewed. Social relationships are among the most crucial issues that should be noticed. As expressed previously, solid scientific evidence shows that social relationships affect health behaviors, mental health, physical health, and mortality risk. In addition, social relationships benefit health beyond target individuals by influencing the health of others throughout social networks. This implies that a simple strategy that focuses on social relationships may prove to be a cost-effective strategy for enhancing health at the population level (Umberson & Montez, 2010). When developing such strategies, investigating the quantity and quality of social relationships and the factors shaping them among wives of Iranian war veterans with PTSD will provide valuable context-based data for these nurses, other health care workers, and health care policymakers. The aim of this study, therefore, was to describe the lived experiences and social relationships of wives of Iranian veterans with PTSD.
Methods Design and sample In this study, a qualitative design with a qualitative content analysis approach was used for data collection and analysis of experiences of wives of Iranian veterans with PTSD concerning their social relationships. Approval to conduct the study was granted by the Research Committee at the Nursing and Midwifery College of Birjand University of
Vagharseyyedin: Experiences of Wives of War Veterans with PTSD Medical Sciences in Birjand, Iran. Ethical approval was also obtained from the director of the Foundation of Martyrs and Veterans of the Southern Khorasan province. Wives of all war veterans with PTSD who were registered in the Foundation of Martyrs and Veterans Affairs from 1980 to January 2012 were eligible for inclusion in the study. There were over 100 veterans on the registry list when the study started, and they were all diagnosed to have PTSD by expert psychiatrists. The exclusion criteria for participants included wives’ having a condition which impeded their social relationships like (1) a history of cognitive impairment or chronic disease such as slowness in thinking seen in Parkinson’s disease or spinal cord injury, or (2) living with another family member with a disability like cerebral palsy. To achieve maximum variance, factors such as wives’ age, duration and percentage of disability of the husbands, and the duration of marital life were considered. Participants were selected by purposive sampling. First, one person was chosen from the registry list and contacted by the researcher. If his wife did not have exclusion criteria and agreed to participate in the study, she was interviewed. Otherwise, another person with similar characteristics was selected and contacted. The participants were informed about the study both orally and in writing and assured of confidentiality. Also participants were informed that they could quit the interview at any point without being penalized. Lastly, informed consent was obtained from the participants. Final sample included 14 wives whose age ranged from 39 to 55 years with an average of 45.5 years. Duration of marital life ranged from 8 to 27 years with a mean of 21 years.
Measures The data were collected through semistructured interviews. Each interview took 45–90 minutes and was conducted in a comfortable and private room at the Foundation of Martyrs and Veterans Affairs in Birjand, the center of the Southern Khorasan province. After completing an initial review of the literature, some guiding interview questions were selected. The interviews began with open-ended questions, and the participants were asked to explain their experiences in detail. Some typical questions were:
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1. Considering your role as a primary caregiver for a husband with a chronic illness, please describe a typical day in your life. 2. Are there any organizations or associations in which you have voluntary cooperation? 3. Please explain the relationship between your family and others in the community. 4. How much do you trust other people in the community, for example, your neighbors? Other questions were formulated by following up on participants’ responses. All the interviews were tape-recorded with participants’ permission. The interviews were subsequently transcribed verbatim immediately after each interview and analyzed concurrently with data collection.
Analytic strategy The data were analyzed using qualitative content analysis according to the recommendations by Morse and Field (1995). The analysis started by identifying the units of meanings that could be extracted from the statements. Then, coding was carried out line by line. Codes with similar meanings were sorted into subcategories. Depending on the relationships between the subcategories, this large number of subcategories was combined into a smaller number of categories. In the final stage, main themes were identified. Regarding trustworthiness, credibility was established through member check and peer check. The participants were contacted after the analysis and were given a full transcript of their respective coded interviews to determine whether the codes matched their experiences. Then, one faculty member from the College of Nursing and Midwifery at Birjand University of Medical Sciences and a nursing doctoral student conducted peer checking.
Results After analyzing the data, two themes emerged: (1) Dynamic interaction between the limited social world and the spiritual world, and (2) Seeking a sensitive and assistive atmosphere. The first theme and its categories are briefly listed in Table 1.
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TABLE 1. Dynamic Interaction between the Limited Social World and the Spiritual World Quotes
Subcategories
If my kids have a problem, they say nothing of their problems to their father, because he gets angry quickly. I have to listen to them and to help them alone After getting up in the morning, I do all the things. He [the patient] does not do anything My husband is dependent on me for doing all the things. Sometimes when I go to school, he may not prepare even a cup of tea for himself until I come back home I cannot go to my children’s school. At the beginning of the year, I usually tell the teachers that I cannot visit the school during the year. I cannot even attend the Parents- Teachers meetings. Because most of these meetings are held in the afternoon when my husband is at home and I should stay with him Kids are not comfortable with their father. He has repeatedly beaten them. They are not happy to stay at home alone with him. I cannot go anywhere and when I travel, I take my elder daughter with me because she says, “I am scared of being alone at home with my daddy”. I take her with me wherever I go We have a lot of conflicts at home, so I cannot have a useful activity outside of the home. After getting up and doing ordinary household chores, I have to wait to get through the day Even though he made me nervous, I loved my family. I told myself I must maintain my family After marriage, the symptoms of his illness [my husband] were raised little by little. Well, this was my destiny. I could not do anything to change it My kids are the most important things for me. I am in charge of their destiny. Believe that if I didn’t have my kids, I would not tolerate this situation anymore. I must sacrifice myself and deal with the problems Veterans did not go to the battlefield for their own sake; they went to the battlefield for the God sake. If I take care of him, God will reward me Despite all the problems, we trust in God. We do not expect anyone to help us I believe everyone in the world will be somehow tested. I think my husband’s problem is a kind of examination for me. I am ready to bear even more problems
Having additional roles in the family
Categories
Theme
Imbalance between personal and social life
Ongoing interaction between the limited social world and the spiritual world
Disrupted social activities
Complete desire to maintain the family foundation
Buffering role of value and belief systems
Believing in the existence of a divine plan in life
The emerged themes indicated that the participants had a limited social relationship.
Because most of these meetings are held in the afternoon when my husband is at home and I should stay with him.
Dynamic interaction between the limited social world and the spiritual world The majority of participants believed that the illness of their husband had caused them not to be able to have social activities outside of the home. This was clearly reflected in the statement one of the participants made:
Another participant said:
I cannot go to my children’s school. At the beginning of the year, I usually tell the teachers that I cannot visit the school during the year. I cannot even attend the Parents- Teachers meetings.
Early in the [Islamic] Revolution, when my husband has not been injured yet, I worked in the Basij Organization, but after his injury, I could not cooperate with Basij anymore, because I had to do all the household tasks.
Furthermore, the illness of participants’ husbands had caused the wives to inevitably undertake the duties of their husbands in the family, and thus the chance of their relationship with the world outside home was limited. One participant stated, “If my
Vagharseyyedin: Experiences of Wives of War Veterans with PTSD kids have a problem, they say nothing of their problems to their father because he gets angry quickly. I have to listen to them and help them alone”. Another participant said, “My husband is dependent on me for doing all the things. Sometimes when I go to school, he may not prepare even a cup of tea for himself until I come back home”. Considering limited social activities outside of the home, the wives felt that their lives were not spent efficiently and effectively, so they could not have an effective role in society. As one of them noted, “We have a lot of conflicts at home, so I cannot have a useful activity outside of the home. After getting up and doing ordinary household chores, I have to wait to get through the day”. However, almost all participants stated that although there was an imbalance between their personal and social lives, they could tolerate the problems and were still interested in living with their husbands. A participant stated, “Even though he made me nervous, I loved my family. I told myself I must maintain my family”. Another participant stated, “After marriage, the symptoms of his illness [my husband] were raised little by little. Well, this was my destiny. I could not do anything to change it”. Experiences of participants suggested that their value and belief system played an important role in their dealing with the aforementioned problems. For example, one of the wives believed that sacrificing her life for her children was the reason for continuing to live with a veteran who is diagnosed with psychiatric problems. She stated: My kids are the most important things for me. I am in charge of their destiny. Believe that if I didn’t have my kids, I would not tolerate this situation anymore. I must sacrifice myself and deal with the problems.
For other participants, bearing the problems is considered as a divine test. Some participants tried to provide a reliable umbrella for themselves against stresses through religious beliefs. In line with this, one participant noted, “Veterans did not go to the battlefield for their own sake; they went to the battlefield for the God sake. If I take care of him, God will reward me”. And another one said, “I believe everyone in the world will be somehow tested. I think my husband’s problem is a kind of examination for me. I am ready to bear even more problems”.
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Seeking a sensitive and assistive atmosphere According to participants, war veterans suffering from PTSD experienced more problems than veterans with physical disorders. Thus, wider areas of family life of war veterans with PTSD were negatively affected by these problems. However, a majority of participants believed that, generally, people in society were unaware of many of these problems. One participant described her experience as follows: I think people understand the situation of veterans that are amputee or ones who are sitting on a wheelchair better. They respect them more than they respect veterans with mental illness. But I believe veterans with mental problems suffer no fewer problems than these veterans.
This unrealistic perception of the problems of families caring for a member with PTSD, according to the partcipants’ remarks, has caused many people in society to have a negative viewpoint toward the few privileges that various organizations designated to the family members of those veterans diagnosed with PTSD and therefore consider them unfair. This is evident as a participant said, “If Education Organization privileges me, my colleagues would get upset. They say that my husband is wounded, so why should I be privileged. They don’t know how it is to live with a mentally-ill patient”. Almost all participants believed that society did not consider the complex problems of veterans with PTSD and their families. Therefore, they strongly felt that society had not a clear and comprehensive program for improving the families’ situation. Participants perceived this lack of attention to increase over time. One wife said: People cared more about veterans in the first years after the war. But now a lot of time has passed since my husband got injured, and it seems that people have forgotten about them. But if it were not for them [veterans], we wouldn’t be at peace now.
One hand, they wanted people to understand them and have a realistic image of the issues and problems associated with living with a veteran suffering from war-related PTSD. On the other hand, they expressed an unwillingness to discuss their family problems with others such as neighbors and strangers. In some cases, distrust of neighbors was among the reasons for this unwillingness. Others considered family issues as a secret that no neighbor should be aware of and that they
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should manage the issues themselves. This was reflected in the following statement, “I don’t like neighbors to realize my problems at all. When my kids were small, I had to put up with problems alone. Now that my son is 21, I have to endure more [and not disclose the problems]”. In general, participants were seeking more respect toward them. They expected to be honored for services that they believed their husband had offered to their country and fellow people. One participant stated: My husband was a military officer that was injured. I hear some neighbors say that he was a military officer, and he had to go to war. It was his job to do so. He is injured, but he wasn’t a volunteer.
Wives in the study also frequently emphasized the importance of social support provided by relatives, friends, and neighbors. One participant mentioned: One day my husband got sick. I didn’t have much cash in house. I called emergency medical service […]. I remember he was hospitalized for 3 or 4 days. I had to leave my kids alone in the house. None of the relatives dared to check on our family.
Although participants pointed out the need for social support, PTSD symptoms of veterans had led to infrequent interactions with relative and friends. One participant stated, “Relatives come to our home. They don’t mean it but if they speak loudly my husband would get nervous and starts quarreling and they would get upset”. Another participant said, “If kids’ friends are around, my husband might suddenly get nervous. I constantly have to worry that they don’t get aware of our problems. So, kids are not having much relation with their classmates or friends”. Considering such conditions, participants expected instrumental and emotional support from society and organizations in charge. The following quotes from wives interviewed evidently indicate what these participants want: My 16-year-old daughter had a car accident last year. We had two patients in our home. One was my husband, and the other was my daughter. I went to Welfare Organization of Iran. They admitted her. I thought that it would be good if they pay for her medical expenses […], but they have not called for a year.
Or, […] Well, you’d expect that Foundation [Foundation of Martyrs and Veterans Affairs] would ask about veterans’ family or greet them once in a while. That is enough for us. But if we don’t ask them anything, they wouldn’t bother with us.
Discussion The purpose of this study was to describe the lived experiences of wives of Iranian veterans with PTSD concerning their social relationships. In this study, analysis of the interviews revealed two main themes: (1) Dynamic interaction between the limited social world and the spiritual world, and (2) Seeking a sensitive and assistive atmosphere. These themes indicated that the participants did not generally have good social relationships. Difficulties of living with war veterans suffering from PTSD had led to disruption in social activities for them. The wives believed that because of the PTSD symptoms of their husbands, they had unwillingly accepted a large part of responsibilities in their family. This finding, described by researchers as a “redistribution of roles and a redivision of work” (Harkness & Zador, 2001), has been a common finding in other studies on wives of veterans with PTSD. In a study by Hayes et al. (2010), for instance, spouses of veterans with PTSD experienced considerable difficulties in managing all of the demands placed on them. According to this finding, when adopting or designing programs to improve health of families of veterans with PTSD, it is critical for nurses and other health care professionals to pay a particular attention to the pivotal, yet very complex, role of wives in these families. The responsibility overload in family was highlighted as a factor limiting social activities by the participants. Similar to this finding, Kessler (2000) found that social isolation is one of the common traits of PTSD. Nurses have traditionally been at the interface between health care and social care systems, between health care professionals and patients and, finally, between patients and their families (Lauder, Reel, Farmer, & Griggs, 2006). So, public health nurses can use this potential to build links between wives of veterans with PTSD and different groups in such systems. Also, nurses can hold monthly meetings for the wives. These meetings can help
Vagharseyyedin: Experiences of Wives of War Veterans with PTSD families develop and share common meanings within the community. In these sessions, establishing and nurturing relationships are more important than the content discussed by wives (Looman & Lindeke, 2005). It is noteworthy that in baccalaureate undergraduate nursing programs in Iran, community/ public health is viewed as an essential content. In addition, specialty programs in public/community health nursing exist at the master’s degree level. Nonetheless, the potentials of public health nursing system have not been fully used in Iran, especially in urban areas (Adib-Hajbaghery, 2013). In fact, the role of public health nurses often limits to well baby care, health education, family planning, and immunization in health care centers, providing care in schools, and activity in clinics for special diseases or research centers. Most of the findings of this study are associated with issues that either directly or indirectly fall among the assumed responsibilities of public health nurses around the world. Therefore, our findings strongly emphasize the necessity for establishment of an advanced public health nursing system with competent nursing staff which addresses the needs and health priorities in Iranian community. Nevertheless, our findings have important messages for nurses and other health care professionals who are in contact with family members of veterans with PTSD. For example, nurses who work in schools should be aware of the effects of PTSD on children and try to provide them with special support. Another important finding of this study was that despite numerous social and family problems, there was an evident preference among the participants to continue living with veterans and maintain the family. In contrast with this finding, some studies have reported a higher divorce rate in families of veterans with PTSD than in families of veterans without PTSD or the general population (King, Taft, King, Hammond, & Stone, 2006). Considering the cultural background and religious beliefs of participants, this finding was not unexpected. In Iran, Islam is the dominant religion. According to the Islamic philosophy of life, there is a transcendental dimension to pain and suffering. Pain is a form of test or trial to confirm a believer’s spiritual station (Zahedi & Larijani, 2007). Muslims believe that suffering is a part of life, and forbearance of hardship is greatly rewarded (Hedayat, 2006). In view of
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their value system, wives participating in our study sought a new meaning and value for life. In other words, despite the difficulties of living with a mental patient, religious belief and value systems could motivate the wives. Lack of realistic understanding by society of the difficulties of families caring for a member with PTSD was frequently emphasized by participants. One possible explanation of this finding is that, as the participants stated, they were not willing to share their family problems and stories with others. Total sharing and individual privacy are deeply rooted in cultural ideals of individuals toward groups and relationships (Checton, Greene, Magsamen-Conrad, & Venetis, 2012). Therefore, it could be assumed that cultural backgrounds and social norms of participants have limited them in disclosing and having intimate conversations on personal and familial matters with neighbors, close friends, and strangers. Under these conditions, it is obvious that realistic understanding of the participants’ conditions is nearly impossible for other members of society. This has caused participants to feel that people in society have low compassion for them. Moreover, participants sought to be treated respectfully by the society. As the presented image of a specific part of society by mass media is frequently understood as a measure of social value for that group, mass media can be an effective tool in correcting society’s viewpoint toward families of veterans with PTSD and improving their social status. In Iran, nurses as representatives of influential associations and organizations such as Iranian Nursing Organization (INO) can play a critical role in convincing authorities regarding the need for devising appropriate strategies to improve public perception of the problems families caring for a relative diagnosed with PTSD are facing. The need for enough social support was another major finding that participants confirmed. Consistent with our findings, the need for receiving enough social support is highlighted in many studies on families caring for a member with a chronic illness. For example, Saunders and Byrne (2002) conducted a study with the goal of identifying the experiences of families living with a member who has schizophrenia. One of the categories revealed in their study was the “family and friends” that reflected participants’ need for additional support in caring for the member with schizophrenia, their
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gratitude for support received, and acknowledgment of losses of some family and friends due to the illness. The PTSD symptoms may result in decreased social support, as in the aforementioned study. In fact, PTSD may cause considerable tension in a veteran’s personal relationships which in turn negatively influences social support (in the form of a positive home coming reception, strong family relationships, and strong social networks) (Bolton, Litz, Glenn, Orsillo, & Roember, 2002; Koenen, Stellman, Stellman, & Sommer, 2003; Ruscio, Weathers, King, & King, 2002). Our findings also confirmed this idea. The participants in this study stressed the disrupted interactions with relatives due to PTSD symptoms of their husbands. As time goes by and social networks of families of these veterans deteriorate, it is expected that the amount of their perceived social support decreases. This assertion is supported by previous studies. King et al. (2006), for instance, found that while veterans without PTSD perceived their social support to rise over time, veterans with PTSD perceived that support declines over time. Therefore, nurses and counselors who work with these families should focus on fostering the interpersonal relationships of the veterans with PTSD, improving the existing social support, and establishing new social networks such as peer support groups. Finally, the participating wives were expecting responsible organizations to provide them with tangible assistance such as financial and emotional support. Although Foundation of Martyrs and Veterans Affairs as, a relevant organization, is providing financial support to these families, considering the treatment expenses of PTSD as well as limited capability of husbands for work and additional income, devising appropriate policies and programs that are comprehensive and providing financial and emotional support for these families are necessary. In public health nursing, the emphasis is on partnership working that cuts across disciplinary, professional, and organizational boundaries that impact on social and political policy to promote the health of whole populations (Nursing & Midwifery Council, 2004). Therefore, in countries where public health nursing system has developed well, public health nurses are in a key position to work in conjunction with social service workers, decision makers, and health care policymakers to design
effective interventions that support these families. In countries such as Iran, an activity of INO or Foundation of Martyrs and Veterans can be recommended to promote cooperation among relevant organizations through holding meetings and coming to conclusions concerning regulations, ways of interactions, and duties of each organization in order to meet special needs of these families. Due to the qualitative nature of this study, the results of this study cannot be completely generalized to all regions in which families of veterans with PTSD live. However, the results can be used for comparing the diverse perceptions of veterans’ wives about the factors contributing to their social relationships in different countries. The problems emphasized by participants such as disrupted social activities and the need for additional social support can provide some direction for priority setting of problems in this specific population. Finally, considering the fact that social relationships within the community affect health, the health standards of these families will be promoted by improving the elements shaping the social relationships confirmed by the participants. Future studies also should focus on the development and evaluation of public health interventions for improving the social lives of wives of patients diagnosed with PTSD and investigating other aspects of their personal and social lives.
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Archive of Psychiatric Nursing, 16(5), 217– 223. Shalev, A. Y. (2002). Acute stress reactions in adults. Biological Psychiatry, 51(7), 532–543. Smith, K. P., & Christakis, N. A. (2008). Social networks and health. Annual Review of Sociology, 34, 405–429. Umberson, D., & Montez, J. K. (2010). Social Relationships and Health: A flashpoint for health policy. Journal of Health and Social Behavior, 5, S54–S66.
Willis, J. (2009). Community development in public health and primary care. In D. Sines, M. Saunders & J. Forbes-Burford (Eds.), Community health care nursing (pp. 50–52). Chichester: Wiley-Blackwell. Zahedi, F., & Larijani, B. (2007). Cancer ethics from the Islamic point of view. Iranian Journal of Allergy, Asthma and Immunology, 6, S17–S24.
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Experiences of Wives of Iranian War Veterans with Posttraumatic Stress Disorder Regarding Social Relationships Seyyed A. Vagharseyyedin, B.Sc., M.Sc., Ph.D. Faculty of Nursing and Midwifery, Birjand University of Medical Sciences, Birjand, Iran Correspondence to: Seyyed A. Vagharseyyedin, Nursing and Midwifery College, Birjand University of Medical Sciences, Ayatollah Ghaffari Avenue, Birjand 97175-379, Iran. E-mail: [email protected]
ABSTRACT Objective: The aim of this study was to describe the lived experiences of wives of Iranian veterans with PTSD concerning their social relationships. Design and Sample: A qualitative design with a qualitative content analysis approach was used for data collection and analysis of wives experiences. Fourteen wives of war veterans with PTSD participated in this study. Measures: Qualitative data were collected using in-depth semistructured interviews. Results: Two themes emerged from the analysis: (1) Dynamic interaction between the limited social world and the spiritual world, and (2) Seeking a sensitive and assistive atmosphere. Disruption of social activities, necessity of the publics realistic perception of families problems, and the need for additional social support were among the most emphasized points made by participants. Conclusions: Findings of the study can provide some direction for priority setting of problems and designing interventions to improve social lives of wives of Iranian patients diagnosed with PTSD. Further, the findings provide a base for comparing similar possible studies conducted in other societies with the Iranian society. Key words: content analysis, Iran, PTSD, social relationships, wives of war veterans.
Posttraumatic stress disorder (PTSD) is a mental health problem that can occur after witnessing or directly experiencing life-threatening events such as natural disasters, terrorist incidents, serious accidents, or combat. People who suffer from PTSD often experience symptoms such as difficulty in sleeping, nightmares, uncontrollable thoughts, and depression (Blum et al., 2012; Lamprecht & Sack, 2002). Approximately, one third of patients diagnosed with PTSD progress to chronic and unremitting disease (Blum et al., 2012) that may significantly impair their ability to function normally in social life (Iribarren, Prolo, Neagos, & Chiappelli, 2005). High rates of PTSD in war veterans have been found throughout history (Shalev, 2002). Unfortunately, the prevalence of PTSD among Iranian war veterans is unknown. However, considering the
8-year-long Iran-Iraq war, it can be inferred that there are likely to be numerous war veterans suffering from this disorder in Iran. Previous research shows that PTSD, as a chronic disease, not only affects the quality of life of war veterans but also creates a huge burden on their caregivers and families (Devilly, 2002). The process of caring for someone who has been traumatized makes the caregiver vulnerable to impaired social relations, burnout, depression, suicidal ideation, and psychiatric problems such as high levels of subjective stress (Klaric et al., 2010; MangunoMire et al., 2007). In Iran, the majority of male war veterans with PTSD live at home with the assistance of their wives. Given the cultural background of Iranian society, the wives are expected to provide all the support that veterans with PTSD need. In fact, after PTSD
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develops in husbands, their wives often enter into new roles without formal education, and thus become susceptible to the abovementioned problems. As a population at risk in terms of psychosocial problems, wives of patients with PTSD should be targeted by public health nursing services. Public health nurses at the generalist or specialist level empower individuals and others to improve their own health and well-being, and to minimize the effects of specific health conditions (Willis, 2009). In view of the frequent contact of these nurses with families caring for a member with PTSD in a real-world context, they enjoy a good chance to collect the valid data to guide interventions to promote the well-being of this population. Obviously, such an opportunity is more available to the nurses in countries where there is an advanced public health nursing system. These interventions are expected to be designed within an evidence-based practice framework. Evidence-based practice provides nurses with a method to use critically appraised and scientifically proven evidence for delivering effective health care to a specific population (Majid et al., 2011). Certainly, implementing evidence-based practice is possible only when enough research evidence is available. Nevertheless, a review of the related literature to PTSD conducted in Iran demonstrates that most research on PTSD has focused on the veterans, and what is lacking is information regarding the experiences of wives of the Iran-Iraq war veterans with PTSD. The wives of Iranian war veterans with PTSD, especially unemployed ones, spend more time at home and possibly may have limited social relationships. This can in addition aggravate their psychological problems (Dekel, Goldblatt, Keider, Solomon, & Polliack, 2005). Social relationships as a source of support are also considered as mechanisms for enhancing population health and well-being. Over the past years, several studies have provided consistent evidence linking a low quantity or quality of social relationships with a host of conditions, including development and progression of cardiovascular disease, high blood pressure, and dysregulation of immune function (Bell, Thorpe, & Laveist, 2010; Everson-Rose & Lewis, 2005). Social isolation, social integration, social support, and social networks have been described
as features of social relationships (Umberson & Montez, 2010). Social isolation refers to the relative absence of social relationships. Social integration is the overall level of involvement with formal and informal social relationships. Social networks include the web of social relationships surrounding an individual. Social support generally refers to a more focal set of relationships such as an individual’s friends and family (Gapen et al., 2011; Smith & Christakis, 2008). Since nurses, especially public health nurses, have a commitment to their community for the prevention of illnesses and provision of holistic care, they must recognize and address concerns of wives of patients with PTSD. During assessment of health status of these clients, the environmental, psychosocial, and cultural factors that may influence the potential to achieve or maintain health should be viewed. Social relationships are among the most crucial issues that should be noticed. As expressed previously, solid scientific evidence shows that social relationships affect health behaviors, mental health, physical health, and mortality risk. In addition, social relationships benefit health beyond target individuals by influencing the health of others throughout social networks. This implies that a simple strategy that focuses on social relationships may prove to be a cost-effective strategy for enhancing health at the population level (Umberson & Montez, 2010). When developing such strategies, investigating the quantity and quality of social relationships and the factors shaping them among wives of Iranian war veterans with PTSD will provide valuable context-based data for these nurses, other health care workers, and health care policymakers. The aim of this study, therefore, was to describe the lived experiences and social relationships of wives of Iranian veterans with PTSD.
Methods Design and sample In this study, a qualitative design with a qualitative content analysis approach was used for data collection and analysis of experiences of wives of Iranian veterans with PTSD concerning their social relationships. Approval to conduct the study was granted by the Research Committee at the Nursing and Midwifery College of Birjand University of
Vagharseyyedin: Experiences of Wives of War Veterans with PTSD Medical Sciences in Birjand, Iran. Ethical approval was also obtained from the director of the Foundation of Martyrs and Veterans of the Southern Khorasan province. Wives of all war veterans with PTSD who were registered in the Foundation of Martyrs and Veterans Affairs from 1980 to January 2012 were eligible for inclusion in the study. There were over 100 veterans on the registry list when the study started, and they were all diagnosed to have PTSD by expert psychiatrists. The exclusion criteria for participants included wives’ having a condition which impeded their social relationships like (1) a history of cognitive impairment or chronic disease such as slowness in thinking seen in Parkinson’s disease or spinal cord injury, or (2) living with another family member with a disability like cerebral palsy. To achieve maximum variance, factors such as wives’ age, duration and percentage of disability of the husbands, and the duration of marital life were considered. Participants were selected by purposive sampling. First, one person was chosen from the registry list and contacted by the researcher. If his wife did not have exclusion criteria and agreed to participate in the study, she was interviewed. Otherwise, another person with similar characteristics was selected and contacted. The participants were informed about the study both orally and in writing and assured of confidentiality. Also participants were informed that they could quit the interview at any point without being penalized. Lastly, informed consent was obtained from the participants. Final sample included 14 wives whose age ranged from 39 to 55 years with an average of 45.5 years. Duration of marital life ranged from 8 to 27 years with a mean of 21 years.
Measures The data were collected through semistructured interviews. Each interview took 45–90 minutes and was conducted in a comfortable and private room at the Foundation of Martyrs and Veterans Affairs in Birjand, the center of the Southern Khorasan province. After completing an initial review of the literature, some guiding interview questions were selected. The interviews began with open-ended questions, and the participants were asked to explain their experiences in detail. Some typical questions were:
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1. Considering your role as a primary caregiver for a husband with a chronic illness, please describe a typical day in your life. 2. Are there any organizations or associations in which you have voluntary cooperation? 3. Please explain the relationship between your family and others in the community. 4. How much do you trust other people in the community, for example, your neighbors? Other questions were formulated by following up on participants’ responses. All the interviews were tape-recorded with participants’ permission. The interviews were subsequently transcribed verbatim immediately after each interview and analyzed concurrently with data collection.
Analytic strategy The data were analyzed using qualitative content analysis according to the recommendations by Morse and Field (1995). The analysis started by identifying the units of meanings that could be extracted from the statements. Then, coding was carried out line by line. Codes with similar meanings were sorted into subcategories. Depending on the relationships between the subcategories, this large number of subcategories was combined into a smaller number of categories. In the final stage, main themes were identified. Regarding trustworthiness, credibility was established through member check and peer check. The participants were contacted after the analysis and were given a full transcript of their respective coded interviews to determine whether the codes matched their experiences. Then, one faculty member from the College of Nursing and Midwifery at Birjand University of Medical Sciences and a nursing doctoral student conducted peer checking.
Results After analyzing the data, two themes emerged: (1) Dynamic interaction between the limited social world and the spiritual world, and (2) Seeking a sensitive and assistive atmosphere. The first theme and its categories are briefly listed in Table 1.
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TABLE 1. Dynamic Interaction between the Limited Social World and the Spiritual World Quotes
Subcategories
If my kids have a problem, they say nothing of their problems to their father, because he gets angry quickly. I have to listen to them and to help them alone After getting up in the morning, I do all the things. He [the patient] does not do anything My husband is dependent on me for doing all the things. Sometimes when I go to school, he may not prepare even a cup of tea for himself until I come back home I cannot go to my children’s school. At the beginning of the year, I usually tell the teachers that I cannot visit the school during the year. I cannot even attend the Parents- Teachers meetings. Because most of these meetings are held in the afternoon when my husband is at home and I should stay with him Kids are not comfortable with their father. He has repeatedly beaten them. They are not happy to stay at home alone with him. I cannot go anywhere and when I travel, I take my elder daughter with me because she says, “I am scared of being alone at home with my daddy”. I take her with me wherever I go We have a lot of conflicts at home, so I cannot have a useful activity outside of the home. After getting up and doing ordinary household chores, I have to wait to get through the day Even though he made me nervous, I loved my family. I told myself I must maintain my family After marriage, the symptoms of his illness [my husband] were raised little by little. Well, this was my destiny. I could not do anything to change it My kids are the most important things for me. I am in charge of their destiny. Believe that if I didn’t have my kids, I would not tolerate this situation anymore. I must sacrifice myself and deal with the problems Veterans did not go to the battlefield for their own sake; they went to the battlefield for the God sake. If I take care of him, God will reward me Despite all the problems, we trust in God. We do not expect anyone to help us I believe everyone in the world will be somehow tested. I think my husband’s problem is a kind of examination for me. I am ready to bear even more problems
Having additional roles in the family
Categories
Theme
Imbalance between personal and social life
Ongoing interaction between the limited social world and the spiritual world
Disrupted social activities
Complete desire to maintain the family foundation
Buffering role of value and belief systems
Believing in the existence of a divine plan in life
The emerged themes indicated that the participants had a limited social relationship.
Because most of these meetings are held in the afternoon when my husband is at home and I should stay with him.
Dynamic interaction between the limited social world and the spiritual world The majority of participants believed that the illness of their husband had caused them not to be able to have social activities outside of the home. This was clearly reflected in the statement one of the participants made:
Another participant said:
I cannot go to my children’s school. At the beginning of the year, I usually tell the teachers that I cannot visit the school during the year. I cannot even attend the Parents- Teachers meetings.
Early in the [Islamic] Revolution, when my husband has not been injured yet, I worked in the Basij Organization, but after his injury, I could not cooperate with Basij anymore, because I had to do all the household tasks.
Furthermore, the illness of participants’ husbands had caused the wives to inevitably undertake the duties of their husbands in the family, and thus the chance of their relationship with the world outside home was limited. One participant stated, “If my
Vagharseyyedin: Experiences of Wives of War Veterans with PTSD kids have a problem, they say nothing of their problems to their father because he gets angry quickly. I have to listen to them and help them alone”. Another participant said, “My husband is dependent on me for doing all the things. Sometimes when I go to school, he may not prepare even a cup of tea for himself until I come back home”. Considering limited social activities outside of the home, the wives felt that their lives were not spent efficiently and effectively, so they could not have an effective role in society. As one of them noted, “We have a lot of conflicts at home, so I cannot have a useful activity outside of the home. After getting up and doing ordinary household chores, I have to wait to get through the day”. However, almost all participants stated that although there was an imbalance between their personal and social lives, they could tolerate the problems and were still interested in living with their husbands. A participant stated, “Even though he made me nervous, I loved my family. I told myself I must maintain my family”. Another participant stated, “After marriage, the symptoms of his illness [my husband] were raised little by little. Well, this was my destiny. I could not do anything to change it”. Experiences of participants suggested that their value and belief system played an important role in their dealing with the aforementioned problems. For example, one of the wives believed that sacrificing her life for her children was the reason for continuing to live with a veteran who is diagnosed with psychiatric problems. She stated: My kids are the most important things for me. I am in charge of their destiny. Believe that if I didn’t have my kids, I would not tolerate this situation anymore. I must sacrifice myself and deal with the problems.
For other participants, bearing the problems is considered as a divine test. Some participants tried to provide a reliable umbrella for themselves against stresses through religious beliefs. In line with this, one participant noted, “Veterans did not go to the battlefield for their own sake; they went to the battlefield for the God sake. If I take care of him, God will reward me”. And another one said, “I believe everyone in the world will be somehow tested. I think my husband’s problem is a kind of examination for me. I am ready to bear even more problems”.
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Seeking a sensitive and assistive atmosphere According to participants, war veterans suffering from PTSD experienced more problems than veterans with physical disorders. Thus, wider areas of family life of war veterans with PTSD were negatively affected by these problems. However, a majority of participants believed that, generally, people in society were unaware of many of these problems. One participant described her experience as follows: I think people understand the situation of veterans that are amputee or ones who are sitting on a wheelchair better. They respect them more than they respect veterans with mental illness. But I believe veterans with mental problems suffer no fewer problems than these veterans.
This unrealistic perception of the problems of families caring for a member with PTSD, according to the partcipants’ remarks, has caused many people in society to have a negative viewpoint toward the few privileges that various organizations designated to the family members of those veterans diagnosed with PTSD and therefore consider them unfair. This is evident as a participant said, “If Education Organization privileges me, my colleagues would get upset. They say that my husband is wounded, so why should I be privileged. They don’t know how it is to live with a mentally-ill patient”. Almost all participants believed that society did not consider the complex problems of veterans with PTSD and their families. Therefore, they strongly felt that society had not a clear and comprehensive program for improving the families’ situation. Participants perceived this lack of attention to increase over time. One wife said: People cared more about veterans in the first years after the war. But now a lot of time has passed since my husband got injured, and it seems that people have forgotten about them. But if it were not for them [veterans], we wouldn’t be at peace now.
One hand, they wanted people to understand them and have a realistic image of the issues and problems associated with living with a veteran suffering from war-related PTSD. On the other hand, they expressed an unwillingness to discuss their family problems with others such as neighbors and strangers. In some cases, distrust of neighbors was among the reasons for this unwillingness. Others considered family issues as a secret that no neighbor should be aware of and that they
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should manage the issues themselves. This was reflected in the following statement, “I don’t like neighbors to realize my problems at all. When my kids were small, I had to put up with problems alone. Now that my son is 21, I have to endure more [and not disclose the problems]”. In general, participants were seeking more respect toward them. They expected to be honored for services that they believed their husband had offered to their country and fellow people. One participant stated: My husband was a military officer that was injured. I hear some neighbors say that he was a military officer, and he had to go to war. It was his job to do so. He is injured, but he wasn’t a volunteer.
Wives in the study also frequently emphasized the importance of social support provided by relatives, friends, and neighbors. One participant mentioned: One day my husband got sick. I didn’t have much cash in house. I called emergency medical service […]. I remember he was hospitalized for 3 or 4 days. I had to leave my kids alone in the house. None of the relatives dared to check on our family.
Although participants pointed out the need for social support, PTSD symptoms of veterans had led to infrequent interactions with relative and friends. One participant stated, “Relatives come to our home. They don’t mean it but if they speak loudly my husband would get nervous and starts quarreling and they would get upset”. Another participant said, “If kids’ friends are around, my husband might suddenly get nervous. I constantly have to worry that they don’t get aware of our problems. So, kids are not having much relation with their classmates or friends”. Considering such conditions, participants expected instrumental and emotional support from society and organizations in charge. The following quotes from wives interviewed evidently indicate what these participants want: My 16-year-old daughter had a car accident last year. We had two patients in our home. One was my husband, and the other was my daughter. I went to Welfare Organization of Iran. They admitted her. I thought that it would be good if they pay for her medical expenses […], but they have not called for a year.
Or, […] Well, you’d expect that Foundation [Foundation of Martyrs and Veterans Affairs] would ask about veterans’ family or greet them once in a while. That is enough for us. But if we don’t ask them anything, they wouldn’t bother with us.
Discussion The purpose of this study was to describe the lived experiences of wives of Iranian veterans with PTSD concerning their social relationships. In this study, analysis of the interviews revealed two main themes: (1) Dynamic interaction between the limited social world and the spiritual world, and (2) Seeking a sensitive and assistive atmosphere. These themes indicated that the participants did not generally have good social relationships. Difficulties of living with war veterans suffering from PTSD had led to disruption in social activities for them. The wives believed that because of the PTSD symptoms of their husbands, they had unwillingly accepted a large part of responsibilities in their family. This finding, described by researchers as a “redistribution of roles and a redivision of work” (Harkness & Zador, 2001), has been a common finding in other studies on wives of veterans with PTSD. In a study by Hayes et al. (2010), for instance, spouses of veterans with PTSD experienced considerable difficulties in managing all of the demands placed on them. According to this finding, when adopting or designing programs to improve health of families of veterans with PTSD, it is critical for nurses and other health care professionals to pay a particular attention to the pivotal, yet very complex, role of wives in these families. The responsibility overload in family was highlighted as a factor limiting social activities by the participants. Similar to this finding, Kessler (2000) found that social isolation is one of the common traits of PTSD. Nurses have traditionally been at the interface between health care and social care systems, between health care professionals and patients and, finally, between patients and their families (Lauder, Reel, Farmer, & Griggs, 2006). So, public health nurses can use this potential to build links between wives of veterans with PTSD and different groups in such systems. Also, nurses can hold monthly meetings for the wives. These meetings can help
Vagharseyyedin: Experiences of Wives of War Veterans with PTSD families develop and share common meanings within the community. In these sessions, establishing and nurturing relationships are more important than the content discussed by wives (Looman & Lindeke, 2005). It is noteworthy that in baccalaureate undergraduate nursing programs in Iran, community/ public health is viewed as an essential content. In addition, specialty programs in public/community health nursing exist at the master’s degree level. Nonetheless, the potentials of public health nursing system have not been fully used in Iran, especially in urban areas (Adib-Hajbaghery, 2013). In fact, the role of public health nurses often limits to well baby care, health education, family planning, and immunization in health care centers, providing care in schools, and activity in clinics for special diseases or research centers. Most of the findings of this study are associated with issues that either directly or indirectly fall among the assumed responsibilities of public health nurses around the world. Therefore, our findings strongly emphasize the necessity for establishment of an advanced public health nursing system with competent nursing staff which addresses the needs and health priorities in Iranian community. Nevertheless, our findings have important messages for nurses and other health care professionals who are in contact with family members of veterans with PTSD. For example, nurses who work in schools should be aware of the effects of PTSD on children and try to provide them with special support. Another important finding of this study was that despite numerous social and family problems, there was an evident preference among the participants to continue living with veterans and maintain the family. In contrast with this finding, some studies have reported a higher divorce rate in families of veterans with PTSD than in families of veterans without PTSD or the general population (King, Taft, King, Hammond, & Stone, 2006). Considering the cultural background and religious beliefs of participants, this finding was not unexpected. In Iran, Islam is the dominant religion. According to the Islamic philosophy of life, there is a transcendental dimension to pain and suffering. Pain is a form of test or trial to confirm a believer’s spiritual station (Zahedi & Larijani, 2007). Muslims believe that suffering is a part of life, and forbearance of hardship is greatly rewarded (Hedayat, 2006). In view of
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their value system, wives participating in our study sought a new meaning and value for life. In other words, despite the difficulties of living with a mental patient, religious belief and value systems could motivate the wives. Lack of realistic understanding by society of the difficulties of families caring for a member with PTSD was frequently emphasized by participants. One possible explanation of this finding is that, as the participants stated, they were not willing to share their family problems and stories with others. Total sharing and individual privacy are deeply rooted in cultural ideals of individuals toward groups and relationships (Checton, Greene, Magsamen-Conrad, & Venetis, 2012). Therefore, it could be assumed that cultural backgrounds and social norms of participants have limited them in disclosing and having intimate conversations on personal and familial matters with neighbors, close friends, and strangers. Under these conditions, it is obvious that realistic understanding of the participants’ conditions is nearly impossible for other members of society. This has caused participants to feel that people in society have low compassion for them. Moreover, participants sought to be treated respectfully by the society. As the presented image of a specific part of society by mass media is frequently understood as a measure of social value for that group, mass media can be an effective tool in correcting society’s viewpoint toward families of veterans with PTSD and improving their social status. In Iran, nurses as representatives of influential associations and organizations such as Iranian Nursing Organization (INO) can play a critical role in convincing authorities regarding the need for devising appropriate strategies to improve public perception of the problems families caring for a relative diagnosed with PTSD are facing. The need for enough social support was another major finding that participants confirmed. Consistent with our findings, the need for receiving enough social support is highlighted in many studies on families caring for a member with a chronic illness. For example, Saunders and Byrne (2002) conducted a study with the goal of identifying the experiences of families living with a member who has schizophrenia. One of the categories revealed in their study was the “family and friends” that reflected participants’ need for additional support in caring for the member with schizophrenia, their
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gratitude for support received, and acknowledgment of losses of some family and friends due to the illness. The PTSD symptoms may result in decreased social support, as in the aforementioned study. In fact, PTSD may cause considerable tension in a veteran’s personal relationships which in turn negatively influences social support (in the form of a positive home coming reception, strong family relationships, and strong social networks) (Bolton, Litz, Glenn, Orsillo, & Roember, 2002; Koenen, Stellman, Stellman, & Sommer, 2003; Ruscio, Weathers, King, & King, 2002). Our findings also confirmed this idea. The participants in this study stressed the disrupted interactions with relatives due to PTSD symptoms of their husbands. As time goes by and social networks of families of these veterans deteriorate, it is expected that the amount of their perceived social support decreases. This assertion is supported by previous studies. King et al. (2006), for instance, found that while veterans without PTSD perceived their social support to rise over time, veterans with PTSD perceived that support declines over time. Therefore, nurses and counselors who work with these families should focus on fostering the interpersonal relationships of the veterans with PTSD, improving the existing social support, and establishing new social networks such as peer support groups. Finally, the participating wives were expecting responsible organizations to provide them with tangible assistance such as financial and emotional support. Although Foundation of Martyrs and Veterans Affairs as, a relevant organization, is providing financial support to these families, considering the treatment expenses of PTSD as well as limited capability of husbands for work and additional income, devising appropriate policies and programs that are comprehensive and providing financial and emotional support for these families are necessary. In public health nursing, the emphasis is on partnership working that cuts across disciplinary, professional, and organizational boundaries that impact on social and political policy to promote the health of whole populations (Nursing & Midwifery Council, 2004). Therefore, in countries where public health nursing system has developed well, public health nurses are in a key position to work in conjunction with social service workers, decision makers, and health care policymakers to design
effective interventions that support these families. In countries such as Iran, an activity of INO or Foundation of Martyrs and Veterans can be recommended to promote cooperation among relevant organizations through holding meetings and coming to conclusions concerning regulations, ways of interactions, and duties of each organization in order to meet special needs of these families. Due to the qualitative nature of this study, the results of this study cannot be completely generalized to all regions in which families of veterans with PTSD live. However, the results can be used for comparing the diverse perceptions of veterans’ wives about the factors contributing to their social relationships in different countries. The problems emphasized by participants such as disrupted social activities and the need for additional social support can provide some direction for priority setting of problems in this specific population. Finally, considering the fact that social relationships within the community affect health, the health standards of these families will be promoted by improving the elements shaping the social relationships confirmed by the participants. Future studies also should focus on the development and evaluation of public health interventions for improving the social lives of wives of patients diagnosed with PTSD and investigating other aspects of their personal and social lives.
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