Variation in Veteran Identity as a Factor in Veteran-Targeted Interventions

The foundational process of claiming or rejecting a sociocultural identity shapes our relationships with others as well as the decisions and choices we make for ourselves (4). Health researchers have found that patients’ identities can serve both as barriers to and facilitators of health care behaviors. For example, Gamst and colleagues (5) found that Latino mental health patients with low ethnic identity also had lower Global Assessment of Functioning scores. Men with strong stereotypical masculine identities have higher rates of depression (6) and are half as likely to obtain preventive health care compared with men with moderate masculine identities (7). Among African-American women, higher rates of racial identification were associated with healthier eating habits (8). Regardless of which sociocultural identity is considered (for example, race, ethnicity, culture, gender, sexual orientation, and religion), identity affects patients’ health and mental health.

As a result, general medical and behavioral health interventions and educational campaigns now more frequently incorporate participant identities. Berger and Rand (9) described identity-based interventions as ones that utilize “identity signaling” to influence behavior, such as by associating healthy behaviors with in-group membership. For example, the “Brother, You’re on My Mind” campaign, publically co-led by the National Institute of Minority Health and Health Disparities and Omega Psi Phi, one of America's oldest African-American fraternities, encourages African-American men to seek and to support each other in seeking mental health care for depression and stress.

Although the use of identity-based interventions is relatively new, there is evidence that tailoring interventions to identity appears to increase intervention efficacy and that failing to do so can have negative consequences. For example, Farrelly and colleagues (10) found that the “truth” antismoking campaign, aimed at the nonconformist values of individuals with an “edgy” identity, was associated with increased antitobacco beliefs in this group, whereas the generic “Think. Don’t Smoke” campaign, which was not tailored to any particular group identity, increased protobacco beliefs. Fleming and colleagues (11) examined the “Man Up Monday” campaign, which encourages men to get testing for sexually transmitted infections on Mondays after engaging in unprotected sex on weekends. Although this campaign’s goal was positive, it relied on hegemonic stereotypes of men as sexually aggressive risk takers with multiple partners, unintentionally implying that men who do not engage in such behaviors are not “real men.” The authors noted that such messages have been linked elsewhere to increased risk-taking behaviors and lower condom use and that the effects of identity-based public health campaigns should be carefully examined.

Veteran identity has been conceptualized as the “veteran’s self-concept that derives from his/her military experience within a sociohistorical context” (12). The U.S. Department of Veterans Affairs (VA) currently uses several veteran identity–based campaigns to encourage good health practices. In advertising mental health services, especially suicide prevention, the VA uses the tagline, “It takes the strength and courage of a warrior to ask for help,” often paired with images of the American flag and soldiers looking troubled. In another poster, a former Marine says, “I knew that if the troops I’d lost could talk, they’d say ‘Come on, you’re living for me now. Pick up your game.’” Such campaigns rest on the presumption that veterans share the in-group values of patriotism, warrior ethos, and “brothers-in-arms” relationships and have positive associations to them. It is unclear how veterans who question or reject such values, for example veterans suffering from Agent Orange exposure (sometimes referred to as “sprayed and betrayed”) or veteran survivors of military sexual trauma perpetrated by fellow service members, might respond to this advertising.

Identity-based interventions are also enacted in the VA through attempts to build staff-veteran therapeutic alliances. In 2012–2013, the VA hired more than 800 peer-support specialists, who the VA stresses are veterans who know how difficult it can be to transition to civilian life and contend with the health effects of one’s service. However, it is not known to what extent these peer specialists embrace veteran identity or what types or range of veteran identities they embrace. This may introduce difficulties in connecting with veterans who are significantly different in their identity, but we currently have no way to evaluate this.

Overall, the impact of veteran identity on veterans’ health behaviors and treatment usage is not known and has been understudied. One of the major limiting factors is the lack of a standardized measure of veteran identity that can quantify variations in key identity features, such as salience (the likelihood that an identity will be activated and performed in a given contextual setting) or emotional valence (the positive or negative emotions an individual associates with an identity). Without such tools, we cannot know whether or how variations in veteran identity affect veterans’ responses to these programs and outreach campaigns.

There are indications that variations in veteran identity result from such factors as serving in a politically controversial war, such as Vietnam, Iraq, or Afghanistan; serving during peacetime; participating in combat; or having had an at least partly negative military experience associated with trauma or discrimination. Gender, race-ethnicity, sexual orientation, being born outside the United States, and other person-level characteristics may also affect veteran identity. For example, several researchers have examined the health care use implications of characteristics such as combat service or involvement in veteran service organizations (VSOs), which may also be proxies for high levels of traditional and positive veteran identification. Harada and colleagues (12) surveyed 2,652 veterans and found that those who were exposed to combat, were in a VSO, or rated their military experience as positive had 2.0–2.3 times increased odds of preferring VA care to care from other sources when compared to their counterparts who did not endorse these experiences; however, veterans who experienced combat or were in a VSO were less satisfied than the other veterans with their outpatient VA care (13).

If higher levels of “traditional positive” veteran identification are linked with preferences for VA care, lower levels may help explain hesitancy to use VA services. Women veterans, for example, may have more complex identifications with veteran status than men because of negative experiences or the association of masculinity with military service. Huynh-Hohnbaum, and colleagues (14) conducted qualitative interviews to better understand women veterans’ insight into veteran identity. Although the women expressed pride in their military service, they acknowledged that it was difficult to see themselves as veterans and to be recognized by others as veterans because of societal stereotypes about veterans. Participants also consistently reported experiences of gender discrimination in the military and, depending on the period of service, at VA facilities after discharge. These experiences led to hesitation about utilizing VA health care services and appeared to contribute to the women’s hesitation in self-assignment of veteran identity.

Suter and colleagues (15) similarly explored the conflict between gender identity and veteran identity by interviewing members of an all-women VSO. The participants reported that civilians did not understand their experiences in the military and that “traditional” VSOs overlooked the contributions of women veterans, and thus they had sought a group of similar women veterans. Members referred to each other as “sisters,” and younger members provided transportation so that older women could remain engaged in VSO activities. By making a slight modification to the traditional VSO structure, the women’s self-identification as veterans was bolstered and helped to create a positive, multigenerational social support network. Similarly, tailoring veteran programs and outreach materials to take into account variations in veteran identities and associated emotions could have wide-ranging positive implications for community involvement, health, and engagement in general medical and behavioral health services.

Researchers studying VA programs or veteran-targeted interventions should consider how variation in veteran identity may affect participant recruitment, participation, and outcomes and how to assess veteran identity. As general medical care and mental health care strive to be more culturally competent and person centered, we must consider the many identities consumers can hold, their complexities, and how views of those identities influence their health and experiences in care.