Abstract
The World Health Organization (WHO; 2004) has asserted that health is a state of complete well-being rather than the absence of health-related symptoms. People with health-related conditions and associated symptoms are therefore not precluded from leading a healthful life. With the proper opportunities and support, they can realize complete well-being (Slade, 2010), a construct that integrates two indicators of a life well lived: psychological and subjective well-being. Psychological well-being reflects a life filled with meaning and purpose, whereas subjective well-being reflects an appraisal of one’s life as satisfactory (Keyes et al., 2002).
Military veterans face threats to their well-being during the transition to civilian life. Some veterans report that transitioning to civilian life results in losing aspects of military service that filled their lives with meaning and positive experiences (e.g., comradery; Brenner et al., 2008). In addition, many veterans experience elevated rates of health conditions such as posttraumatic stress disorder (PTSD), depression, mild traumatic brain injury (mTBI), and somatic symptoms (e.g., pain; Hoge et al., 2007; Tanielian et al., 2008). These conditions further limit veterans’ achievement of life satisfaction and meaning and purpose in life, or life meaning (Seligowski et al., 2012; Sinclair et al., 2016).
Occupational therapy practitioners can use therapeutic activity to promote and sustain veterans’ well-being during the transition to the civilian community despite barriers posed by service-related health conditions (Eakman & Radomski, 2017). However, the mechanisms through which participation in activity promotes well-being in the veteran population are poorly understood. The purpose of this study was to understand whether social support, coping ability, and meaningful activity mediated the relationship between social and community participation and veterans’ well-being. Proposing and testing mechanisms underlying this relationship will offer insight into the qualities of participation capable of enhancing veterans’ well-being, thereby informing treatment theories for activity-based interventions in this population.
Social and Community Participation and Well-Being in Veterans
Social and community participation for veterans refers to engagement in activity that enables interaction with others or fulfills nondomestic roles, thereby fostering successful community reintegration (Chang et al., 2013; Levasseur et al., 2010; Resnik et al., 2012). Successful participation may promote veterans’ health and well-being (e.g., Reilly, 1962). Veterans’ engagement in active and community-based activities such as surfing (Rogers et al., 2014) and yoga (Stoller et al., 2012) has been shown to reduce psychosocial challenges (e.g., PTSD symptoms). However, the mechanisms by which participation promotes veterans’ well-being, despite the presence of psychosocial challenges, are not well understood.
Mediating Mechanisms Between Participation and Well-Being in Veterans
The Model of Meaning of Life Experiences (King, 2004) informs the proposed mediating mechanisms underlying the relationship between participation and well-being. This model posits that well-being is optimized when life experiences foster a sense of self-understanding (understanding oneself and one’s relationship with the world), doing (meaningful activity), and belonging (healthy and supportive relationships with others).
Effective coping ability refers to positively reframing conditions of adversity and taking active steps to alter the source of the adversity (Southwick et al., 2015); it may reflect an aspect of self-understanding that mediates the relationship between participation and well-being. Veterans have reported that their ability to cope with distress facilitates community reintegration (Hawkins et al., 2015). They have also reported that engaging in activities is an effective coping mechanism (Gregg et al., 2016). Effective coping ability, in turn, has been linked to both life meaning (Park et al., 2008) and life satisfaction (Hamarat et al., 2001).
Meaningfulness in daily activity likely captures veterans’ sense of doing and may mediate the relationship between participation and well-being. Meaningful activity refers to engagement in activity that aligns with one’s values and interests, thereby generating a constellation of positive subjective experiences (e.g., a sense of competence; Eakman et al., 2018). Meaningful activity complements observable indicators of participation (e.g., frequency) by reflecting the personally construed experience of activity (Hemmingsson & Jonsson, 2005). Veterans who engage in outdoor pursuits (e.g., rock climbing) or activities that facilitate socialization with others, however, tend to realize greater meaning in their activities, suggesting that social and community-based activity may promote veterans’ experience of meaningful activity (Eakman et al., 2019). Engagement in meaningful activity has been linked to greater life meaning and life satisfaction (Eakman & Eklund, 2012).
Postdeployment social support is an indicator of veterans’ sense of belonging that may also mediate the relationship between participation and well-being. Social support refers to perceived emotional needs fulfillment and tangible assistance provided by one’s social environment (King et al., 2006). Engagement in shared activities (e.g., organized sports) allows veterans to secure and maintain supportive relationships with others (Hawkins et al., 2015). In turn, social support may bolster experiences of life meaning (Church et al., 2013) and life satisfaction (Sheldon et al., 2001).
In this study, we sought to understand the mediating mechanisms that underlie the relationship between veterans’ participation and well-being. We hypothesize that coping ability, meaningful activity, and social support mediate the relationship between participation and two complementary perspectives on well-being: meaning and purpose in life (psychological well-being) and life satisfaction (subjective well-being).
Method
Design and Participants
This study used a nonexperimental, explanatory cross-sectional design. We used a convenience sample of community-based veterans attending a university; a portion of this sample received New Start for Student Veterans (NSSV)–supported education services. NSSV is an educational support program for post-9/11 veterans with service-related injuries that is housed in the occupational therapy department of Colorado State University. After the study’s approval by the university’s institutional review board, participants were invited to take an online survey, and they completed an informed consent before initiating the survey. Recipients of NSSV services were contacted by service providers, and other veterans were reached through the university’s veterans’ benefits office. Between November 2013 and April 2018, 5,106 invitations were sent biannually; 525 veterans completed the survey and received a $10 gift card.
Participants were included if they possessed a valid email address associated with the university. Veteran status, defined as former military personnel (e.g., active duty, reservists), was derived from a self-report item capturing status of military service. Participants were excluded if they were currently active duty, yielding a sample of 389 eligible for analysis.
Instruments
The Table 1 note includes information on the interpretation of all instrument scores.
Descriptive Statistics for Study Variables and Results of Multiple Linear Regression Models Used to Compute b Paths and Direct Effects (c′) for Multiple Mediation Analyses (N = 389)
Note. B = unstandardized regression coefficient; β = standardized regression coefficient; mTBI = mild traumatic brain injury; PTSD = posttraumatic stress disorder; SE = standard error; — = not applicable.
Score interpretation: For participation, higher scores indicate more frequent engagement in social and community-based activities; coping ability, higher scores indicate more adaptive coping skills; meaningful activity, higher scores indicate more meaning in daily activities; social support, higher scores indicate greater perceived social support; life meaning, higher scores indicate greater life meaning; life satisfaction, higher scores indicate greater life satisfaction.
*p < .05.
**p < 0.01.
***p < .001.
Participation
We assessed participation using the Veterans’ Social and Community Participation Assessment, a 5-item assessment of frequency of participation derived from Eakman et al. (2019). A confirmatory factor analysis indicated adequate model fit: χ2(5, N = 389) = 8.63, p = .125; comparative fit index = .99; root mean square error of approximation = .04. The 5 items capture how frequently in the past 4 wk a person has (1) participated in organized sports; (2) socialized in person with friends; (3) attended an arts, sports, or civic activity; (4) participated in an outdoor activity; and (5) participated in a hobby, musical or artistic activity, or civic activity.
Mediators
We assessed coping ability with the Brief Resilient Coping Scale, a psychometrically sound 4-item assessment of coping ability (Sinclair & Wallston, 2004). We assessed meaningful activity using the Engagement in Meaningful Activities Survey, a well-validated 12-item assessment (Eakman, 2012; Goldberg et al., 2002). We assessed social support using the Postdeployment Support Questionnaire, a valid 10-item assessment of perceived social support (Vogt et al., 2008).
Indicators of Well-Being
We assessed life meaning (psychological well-being) using the Meaning in Life Questionnaire–Presence Subscale, a psychometrically sound 5-item measure of meaning in life (Steger et al., 2006). We measured life satisfaction (subjective well-being) using the Satisfaction With Life Scale, a well-validated 5-item assessment of life satisfaction (Diener et al., 1985).
Health Conditions
We assessed depression using the Patient Health Questionnaire Depression Scale (PHQ–9), a psychometrically sound 9-item assessment of depressive symptom severity (Kroenke et al., 2001). We used a cutoff score of 11 to indicate depression (Manea et al., 2012). We measured somatic symptoms using the Patient Health Questionnaire Somatic Symptoms Scale (PHQ–15), a valid 15-item assessment of somatic symptom severity (Kroenke et al., 2002). We assessed PTSD using the Posttraumatic Stress Disorder Patient Checklist–Civilian Version (PCL–C), a well-validated 17-item assessment of PTSD symptom severity (Blanchard et al., 1996). A cutoff score of 50 was used to indicate PTSD (Brewin, 2005). mTBI status was derived using a series of items consistent with Hoge et al. (2008).
Data Analysis
We generated descriptive statistics for all study variables and constructed two multiple mediation models using the PROCESS macro for IBM SPSS Statistics (Version 25.0; IBM Corp., Armonk, NY) to test our hypotheses (Hayes, 2013). Model 1 examined the degree to which coping ability, meaningful activity, and social support mediated the relationship between participation and life meaning. We entered demographic characteristics (age, gender [0 = female, 1 = male], and marital status [0 = not married, 1 = married]) and indicators of health conditions (scores from the PHQ–9, PHQ–15, PCL–C, and mTBI variables [0 = no mTBI, 1 = mTBI]) as covariates. Model 2 examined the degree to which coping ability, meaningful activity, and social support mediated the relationship between participation and life satisfaction. We entered the same covariates into Model 2 as we did in Model 1.
Figure 1 shows the mediation model for life meaning, and Figure 2 shows the mediation model for life satisfaction. Testing mediating mechanisms involves obtaining the a path (i.e., regression of the mediator on participation while adjusting for covariates) and the b path (i.e., regression of the well-being indicators on the mediator while adjusting for participation, other mediators, and covariates). The indirect effects are computed by multiplying the a and b paths (i.e., ab) and reflect the extent to which participation influences well-being through the mediator. The direct effect (i.e., the c′ path) is the relationship between participation and well-being while accounting for the mediators (Hayes, 2013). We used 5,000 bias-corrected resamples to generate estimates (Hayes, 2013) and a 99% confidence interval (CI) to evaluate statistical significance while addressing inflated Type I error. Estimates obtained from the regression models used to compute b and c′ paths are presented and interpreted using a level of significance of α = .01.
Multiple mediator model examining the direct and indirect association of social and community participation and life meaning.
Multiple mediator model examining the direct and indirect association of social and community participation and life satisfaction.
Results
The majority of participants were male (81.7%), and 40.4% were married. The average age was 30.45 yr (standard deviation = 7.34). Most (62.5%) reported a U.S. Department of Veterans Affairs (2020) disability rating, and a notable portion met criteria for mTBI (44.7%), depression (26.5%), and PTSD (19.0%). There was no evidence that participation influenced life meaning (Figure 1; c′ = –0.10, SE = 0.07, p = .129) or life satisfaction (Figure 2; c′ = 0.06, SE = 0.06, p = .342) independently of the proposed mediators. Multiple mediation analyses indicated that participation indirectly influenced both life meaning and life satisfaction through its relationship with meaningful activity, even while accounting for the presence of service-related health conditions. Figures 1 and 2 show that veterans who realized more frequent participation reported greater meaning in their activities (a 2 = 0.50), in turn reporting greater life meaning (b 2 = 0.32 in Figure 1) and life satisfaction (b 2 = 0.29 in Figure 2).
Results indicated statistical significance (i.e., CI > 0) for the indirect effects of participation on life meaning (Figure 1; ab 2 = 0.16, SE = 0.04, 99% CI = [0.07, 0.27]) and life satisfaction (Figure 2; ab 2 = 0.14, SE = 0.03, 99% CI = [0.07, 0.24]) through meaningful activity. Results also indicated that participation indirectly influenced life satisfaction through social support (Figure 2; ab 3 = 0.05, SE = 0.02, 99% CI = [0.01, 0.11]). More frequent participation explained greater social support (a 3 = 0.37), which in turn explained greater life satisfaction (b 3 = 0.14; see Figure 2). Figures 1 and 2 show other estimates (e.g., relationships involving coping ability).
Notably, those who experienced greater depressive symptoms tended to report less life meaning (B = –0.27, SE = 0.09, p < .001) and life satisfaction (B = –0.24, SE = 0.07, p < .001). In addition, those with greater PTSD symptoms tended to have less life satisfaction (B = –0.07, SE = 0.03, p = .014). Table 1 presents the complete results of the multiple regression models.
Discussion
To the best of our knowledge, this is the first study to propose and test mediating mechanisms that may explain the purported relationship between participation and well-being in the veteran population. Our findings indicate that meaningful activity partially explains the relationship between participation and both indicators of well-being, social support partially explains the relationship between participation and subjective well-being, and coping ability is not a factor in the relationship between participation and either indicator of well-being. More important, we observed these relationships even when we accounted for service-related health conditions (i.e., PTSD and depression), which were related to lesser well-being.
Meaningful activity was the only proposed mechanism mediating the relationship between participation and both psychological and subjective well-being. This finding contributes to the mounting evidence that the subjective experience of activity is critical for health and well-being (e.g., Law et al., 1998). In addition, this finding supports the emerging perspective that criteria for veterans’ successful community reintegration should consider individualized pursuits and personal meanings (Fritz et al., 2015).
Current criteria for veterans’ successful community reintegration emphasize the successful resumption of participation, as understood in WHO’s (2001) International Classification of Functioning, Disability and Health (ICF; Resnik et al., 2012). Assessment approaches (e.g., Resnik et al., 2011) tend to emphasize the observable aspects of participation (e.g., frequency, successful performance). Others have critiqued the ICF for its relative lack of emphasis on the subjective experience of participation, including its exclusion of the experience of meaning (Hemmingsson & Jonsson, 2005). We echo this critique in the context of applying the ICF to understand veterans’ community reintegration. We propose that assessments for understanding veterans’ community reintegration include a dimension related to the resumption of personally meaningful activity to complement, rather than supplant, existing assessments that emphasize the observable aspects of participation. Capturing the subjective dimension of participation will therefore guide occupational therapy service delivery that fosters veterans’ well-being during community reintegration.
Our findings that support meaningful activity as a mechanism underlying the relationship between participation and well-being may also inform the development of interventions for veterans with service-related injuries. There is currently a paucity of evidence-based interventions that target the positive aspects of veterans’ well-being, instead focusing on the amelioration of psychosocial difficulties (Bauer et al., 2018). Occupational therapy plays a distinct role in addressing this gap. Indeed, a central principle of the profession recognizes that engagement in activity not only emerges from but also contributes to health and well-being (Eakman, 2013; Reilly, 1962). The current study lends empirical support to treatment theories underlying occupational therapy interventions that support veterans’ sustained engagement in meaningful activity, which can foster a sense of a life well lived, despite the presence of service-related health conditions.
This study indicates that social support partially explains the relationship between participation and subjective well-being (i.e., life satisfaction) among veterans. This finding may also lend empirical support to the development of treatment theories underlying occupational therapy intervention. The supportive presence of others is critical to veterans’ successful community reintegration (Hawkins et al., 2015). Unfortunately, veterans tend to report lower levels of social support than their civilian peers (Eakman et al., 2016), in part because service-related injuries such as PTSD and depression often lead veterans to isolate from friends, family, and the community (Resnik & Allen, 2007). Treatment theories may be developed for occupational therapy interventions that emphasize engagement in activity that enables veterans with service-related injuries to develop and maintain supportive relationships with others, thereby enhancing social support and promoting subjective well-being.
This study did not generate statistical evidence that supports coping ability as an underlying factor in the relationship between veterans’ participation and well-being. This null finding may support a pivot to an exploration of alternative constructs that reflect a sense of self-understanding (King, 2004). For example, self-efficacy (i.e., perceived competence when pursuing a course of action; Bandura, 1977) may be a fruitful area of future inquiry. Veterans have reported that self-efficacy supports successful community reintegration and that it emerges from participation (Hawkins et al., 2015). In addition, perceived autonomy and competence foster life meaning and life satisfaction for both civilians and veterans (Eakman, 2013; Seligowski et al., 2012).
In this study’s sample of veterans, PTSD and depression were associated with decreased psychological and subjective well-being. This finding supports previous research linking service-related injuries to decreased life meaning (Sinclair et al., 2016) and life satisfaction (Seligowski et al., 2012) among veterans. Occupational therapy practitioners concerned with promoting veterans’ well-being could therefore operate in multidisciplinary teams and use strategies to manage symptoms of PTSD and depression, thereby mitigating their negative influences on psychological and subjective well-being (Eakman et al., 2016). In addition, given the occupational performance challenges that often accompany service-related health conditions (Speicher et al., 2014), occupational therapy practitioners may also foster veterans’ well-being by using compensatory techniques that facilitate successful engagement in meaningful and social activities despite the presence of service-related injuries.
Limitations and Directions for Research
This study measured subjective well-being using life satisfaction (Diener et al., 1985). However, subjective well-being encompasses high levels of positive emotion concurrent with low levels of negative emotion (Keyes et al., 2002). Therefore, future studies that explore the relationship between participation and veterans’ subjective well-being should simultaneously include indicators of life satisfaction, positive emotion, and negative emotion.
This study used a well-established and psychometrically sound assessment to capture levels of meaningful activity (Eakman, 2012). However, the specific combinations of meanings (e.g., sense of competence) that veterans experience during particular activities remain poorly understood. Future research could develop an understanding of particular combinations of meanings veterans ascribe to activity and how combinations of personal meanings compare with those of civilian populations. This knowledge would afford a more precise understanding of veterans’ experience of meaningful activity and would further develop activity-based interventions targeting their well-being.
Our study used a convenience sample of veterans who attended a university to understand the relationship between participation and well-being among the general veteran population. Although using convenience samples of university students is a widely adopted approach, findings from such samples do not always generalize to nonstudent populations (Hanel & Vione, 2016). We therefore encourage efforts to replicate current findings in samples of nonstudent veterans. In addition, the cross-sectional design of this study precludes the establishment of causal relationships.
Despite design limitations, this study advances knowledge regarding the covariation of measured constructs in a sample of community-based veterans. The establishment of such knowledge is invaluable during the early stages of rehabilitation intervention development, which requires idea generation and the proposal of treatment theories (Whyte & Barrett, 2012). Future research could harness knowledge of relationships observed in this study to inform the systematic development and evaluation of interventions that target veterans’ well-being, including the eventual deployment of methods capable of establishing causal mechanisms of change (e.g., experimental designs).
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice:
Occupational therapy interventions that facilitate engagement in meaningful and shared activities could be developed to promote veterans’ well-being.
Occupational therapists who support veterans’ community reintegration could include assessments that access meanings associated with participation.
Occupational therapy practitioners may promote veterans’ well-being by working within multidisciplinary teams to address symptoms of PTSD and depression.
Conclusion
The current study found that the meaningfulness of activity partially explained the relationship between social and community-based participation and both psychological and subjective well-being in a sample of veterans. In addition, social support partially explained the relationship between participation and subjective well-being. Thus, veterans’ engagement in activities of greater personal interest and activities that promote social connections is more likely to lead to a meaningful and satisfying life. Occupational therapy practitioners fulfill a distinct role in promoting veterans’ well-being during the transition to civilian life by facilitating sustained engagement in meaningful and shared activities despite the presence of service-related injuries.
Footnotes
Acknowledgments
We thank the participating service members and veterans for expending valuable time and effort to share their experiences with us. We also thank past and present NSSV student veteran coordinators for their assistance with the dissemination of our online survey: Erica Billingsley, Joshua E. Burns, Holly Darnell, Natalie R. Rolle, Cathy Schelly, and Erica Tohtz. Funding for this study was provided through philanthropic support of the NSSV program by a private donor. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, the Department of Veterans Affairs, or the U.S. government.