Hardiness, avoidance coping, and alcohol consumption in war veterans: A moderated mediation study

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1 Received: 18 July 2016 Revised: 17 October 2016 Accepted: 25 October 2016 DOI: /smi.2734 RESEARCH ARTICLE Hardiness, avoidance coping, and alcohol consumption in war veterans: A moderated mediation study Paul T. Bartone 1,2 Bjorn H. Johnsen 2 Jarle Eid 2 Sigurd W. Hystad 2 Jon C. Laberg 2 1 Center for Technology and National Security Policy, National Defense University, Washington, DC, USA 2 Department of Psychosocial Sciences, University of Bergen, Bergen, Norway Correspondence Paul T. Bartone, National Defense University, Center for Technology and National Security Policy, Fort Lesley McNair, Washington, DC 20319, USA. bartonep@gmail.com Funding information United States Army Medical Research and Materiel Command, under the Deployment Related Medical Research Program, Grant/ Award Number: W81XWH Abstract Military personnel often engage in excessive alcohol use after returning from deployments. Thus far, research has paid scant attention to personality factors that may increase or diminish the risk for increased alcohol consumption in this population. The present study explores how psychological hardiness, avoidance coping, and stress exposure may interact to influence alcohol consumption patterns in soldiers following deployment. U.S. Army National Guard soldiers (N = 357) were surveyed shortly after returning from combat operations in Afghanistan. Conditional process analysis was used to test for mediation and moderation effects. Mediation effects were further tested in a replication sample of Norwegian Army soldiers (N = 230) deployed to Kosovo. Findings show that hardiness is a significant (negative) predictor of increased alcohol use and that this relation is mediated by avoidance coping. Further, this effect was moderated by combat stress exposure in the U.S. sample, such that the mediation is stronger for those with greater exposure (moderated mediation). Avoidance coping also mediated the effects of hardiness on alcohol consumption in the Norwegian sample. These findings suggest that avoidance coping and hardiness may be fruitful areas for interventions aimed at reducing risky drinking in high stress groups like the military. KEYWORDS alcohol, avoidance coping, combat stress, hardiness, moderated mediation 1 INTRODUCTION Excessive alcohol use is a familiar problem in military populations throughout history, and it is one that cuts across national boundaries (Jones & Fear, 2011). In recent years, however, problem drinking in the military appears to be on the rise. For example, Bray, Brown, and Williams (2013) report that during the 10 year period from 1998 to 2008, the incidence of binge drinking among U.S. military personnel increased from 35% to 47%. They identified high combat exposure as a significant risk factor for increased heavy drinking, suggesting that the conflicts in Iraq and Afghanistan have contributed to the increase. Other studies point to increases in alcohol consumption by military personnel following deployment, especially to combat zones (Browne et al., 2008; Kelsall et al., 2015; Russell et al., 2014). Another study found that combat deployed soldiers are at higher risk for new onset heavy and binge drinking and alcohol related problems after they return and that this risk is even higher for Reserve and National Guard troops (Jacobson et al., 2008). P. Bartone receives royalties on the hardiness instrument used in this study. Abuse of alcohol carries substantial health risks and interferes with recovery from a range of other deployment related conditions, both physical and mental. For example, a study by the United States Veterans Health Administration found that substance abuse was one of the most common mental health diagnoses among U.S. veterans of Iraq and Afghanistan seeking care in Veterans Administration facilities, after post traumatic stress disorder (PTSD; Seal, Bertenthal, Miner, Sen, & Marmar, 2007). There is also evidence that the risk for alcohol abuse increases with intensity of exposure. Military personnel who experience more extreme combat exposure, more deployments, and combat related injuries are at elevated risk for a range of mental health problems, to include substance abuse (Hoge et al., 2004). A more recent study also found that the likelihood of problem drinking increases in military personnel with more frequent and lengthy deployments (Spera, Thomas, Barlas, Szoc, & Cambridge, 2011). In a large population based study of 88,235 U.S. military personnel returning from deployment to Iraq, Milliken, Auchterlonie, and Hoge (2007) report that in the 3 6 months following deployment, 12% to 15% reported excessive, problematic drinking. Similar to Jacobson et al. (2008), these authors also found that excessive drinking after 498 Copyright 2016 John Wiley & Sons, Ltd. wileyonlinelibrary.com/journal/smi Stress and Health. 2017;33:

2 BARTONE ET AL. 499 deployment was an even greater problem for National Guard and Reserve troops, who were referred for alcohol and substance abuse treatment at a rate three times higher than active duty troops (Milliken et al., 2007). In a review of relevant studies, Schumm and Chard (2012) conclude that increased alcohol abuse in the military is related to high levels of stress, including deployment related stress. In their recent meta analysis, Kelsall et al. (2015) also find that wartime deployment increases the risk of alcohol use disorders in soldiers. In addition to deployments and combat exposure, other risk factors that have been identified include being young, male, and single (Jones & Fear, 2011), and being stationed to remote locations, such as U.S. soldiers stationed in Asia (Bray, Bae, Federman, & Wheeless, 2005). Mental health problems are also associated with drinking problems. In a study of German soldiers deployed to Afghanistan, heavy drinking was associated with mental disorders including affective, anxiety, and sleep disorders (Trautmann et al., 2014). Multiple studies have also found that posttraumatic stress symptoms are frequently associated with increased alcohol problems (Brown, Williams, Bray, & Hourani, 2012; Thandi et al., 2015; Trautmann et al., 2015). Despite these recognized risk factors, much remains unclear about alcohol abuse in military personnel following deployment. As noted by Spera et al. (2011) and also Milliken et al. (2007), the majority of military personnel are resilient in the face of deployment related stressors and do not engage in excessive drinking after returning home. When exposed to the same risk conditions, individuals respond differentially, and not all develop alcohol problems. One area that has not received much attention and may help to explain such individual differences involves personality factors associated with stress resilience and vulnerability. The present study begins to address this shortfall by examining the relation of personality hardiness and coping strategies to alcohol use and abuse in soldiers returning from deployment. Hardiness was first described by Kobasa (1979) as a set of interrelated personality qualities that distinguished healthy from unhealthy executives undergoing a highly stressful corporate restructuring. These qualities are summarized as follows: commitment, the abiding conviction that life is interesting and worth living; control, the belief that one s choices and actions have an important influence on outcomes; and challenge, an adventurous, exploring approach to living. Multiple studies have documented that hardiness operates as a significant moderator or buffer of stress in a variety of occupational groups (Bartone, 1989; Bartone, 2006; Kobasa, Maddi, & Kahn, 1982). Hardiness has appeared as a stress buffer in military groups as well, including U.S. Army casualty assistance workers (Bartone, Ursano, Wright, & Ingraham, 1989), peacekeeping soldiers (Bartone, 1996), Israeli soldiers in combat training (Florian, Mikulincer, & Taubman, 1995), and Norwegian Navy cadets (Bartone, Johnsen, Eid, Laberg, & Brun, 2002). Bartone (Bartone, 1999, 2000) found that combat exposed Gulf War soldiers who were low in hardiness were at higher risk for PTSD symptoms, a finding recently confirmed in veterans of the Iraq conflict (Escolas, Pitts, Safer, & Bartone, 2013). The health benefits of hardiness appear to be due in part to different coping strategies and behaviors characteristically chosen by high versus low hardy persons. In responding to stress, those high in hardiness tend to rely on active, problem solving coping strategies. In contrast, those low in hardiness more often revert to avoidance coping strategies (Kobasa, 1982; Funk, 1992), to include excessive alcohol consumption or drug abuse (Maddi, Wadhwa, & Haier, 1996). A recent meta analytic study confirmed that high hardiness is associated with active coping approaches, while low hardiness is linked to avoidance coping (Eschleman, Bowling, & Alarcon, 2010). The first aim of this exploratory study is thus to investigate the potential influence of hardiness on excessive alcohol use in recently deployed military personnel. Next, we assess the role of avoidance coping as a mediator of alcohol use. Finally, we evaluate whether the mediating role of avoidance coping varies as a function of exposure to combatrelated stressors. These predicted relations are depicted in Figure 1. We predict that soldiers with relatively lower levels of hardiness are more likely to engage in excessive alcohol use, and that the relation between hardiness and alcohol use is mediated by avoidance coping. This hypothesis reflects the assumption that excessive alcohol use is at least partly due to increased avoidance coping tendencies in soldiers who are low in hardiness. We further examine whether this process applies to a greater extent in soldiers who have experienced more combat stress exposure. Considering the studies summarized above showing that people high in hardiness are less likely to experience stress related health problems including alcohol and drug abuse and that hardiness is associated with lower avoidance coping tendencies, we hypothesize that the indirect effect of hardiness on alcohol use through avoidance coping will be greater for soldiers with higher levels of combat stress exposure. Put differently, under high stress conditions, those who are low in hardiness are more likely to engage in avoidance coping behaviors, to include excessive drinking. The study hypotheses are summarized as follows: H1:Hardiness is negatively associated with alcohol use. H2:Avoidance coping is positively associated with alcohol use and mediates the association between hardiness and alcohol use. H3:Stress exposure will moderate the indirect effect of hardiness on alcohol abuse (through avoidance coping). Specifically, the hardiness avoidance coping relation will be stronger when stress exposure is high, and weaker when stress exposure is low (moderated mediation). The primary sample for this research consists of a group of U.S. Army National Guard soldiers who completed questionnaires shortly after their return from a 1 year deployment to Afghanistan. Hypotheses 1 3 were tested in this sample. A partial replication, testing Hypotheses 1 and 2, was conducted using an independent sample of Norwegian soldiers deployed to Kosovo. In order to test for FIGURE 1 The proposed moderated mediation conceptual model

3 500 BARTONE ET AL. moderation and mediation effects, we used conditional process analysis techniques as described by Hayes (2013). it was not possible to assess the potential effects of stress as a moderator in the hardiness avoidance coping relation. 2 METHODS 2.1 Respondents and procedure The study was reviewed and approved by the Institutional Review Board and Human Research Protection Program of the U.S. Army Medical Research and Materiel Command, Fort Detrick Maryland. For the U.S. sample, a voluntary survey was administered to soldiers shortly after their return from a 1 year deployment to Afghanistan. The paper and pencil three page survey was administered during the unit s in processing back to their home station, which occurred during their first week at home. The purpose of the study, to identify potential links between life attitudes, coping strategies, and health habits, was explained to soldiers, and no incentives were offered. Informed consent was obtained, and anonymized codes were used to maintain privacy. Of 508 soldiers available on the day of the survey, 357 completed it for a response rate of 70.3% (due to missing data, eight surveys were later discarded). The military unit was 100% male, and so the sample was also 100% male and ranged in age from 20 to 55 with a mean of years and a standard deviation of In terms of military rank, 61% were lower enlisted (E 4 and below), 33% noncommissioned officers (E 5 and above), and 6% officers. The sample for the replication study consisted of a Norwegian active duty battalion (5 companies) that deployed on a 6 month mission to Kosovo (Kobbeltvedt, Brun, & Laberg, 2004; Solberg, 2007). The study was reviewed and approved by the Norwegian Regional Ethics Committee. Participation in the research was voluntary, and no special incentives were offered. The research was announced at company meetings, and volunteers received surveys in pre addressed return envelopes to maintain privacy. The design was prospective, with data collected over multiple time points before and after the Kosovo deployment. Hardiness and avoidance coping were obtained in a survey given just prior to deployment. Alcohol use was assessed in a survey administered shortly after (2 3 months) return home. Participants were instructed that individual results of the questionnaire would not be seen by anyone in the military organization, and anonymized codes were used to maintain individual privacy. Questionnaires were completed individually and returned in a sealed envelope. Of 884 soldiers in the battalion, 769 completed thetime 1 survey (87%). Respondents to later surveys ranged from a low of 297 (Time 3) to a high of 384 (Time 4). The lower number of respondents during the deployment was due to many soldiers being operationally engaged and unavailable on the day of the survey. A dropout analysis conducted by Solberg (2007) showed no differences across samples at different time points on age, sex, marital status, rank, or deployment experience. Complete data on alcohol consumption, stress exposure, hardiness, and avoidance coping were available for N = 230 cases. The sample was 96% male, with 74% between the ages of 21 30, 20% aged 31 and older, and 5% aged 20 and younger. In terms of rank, 57.6% were lower enlisted and 42.4% officers and non commissioned officers. Because avoidance coping was measured prior in time to stress exposure in the Norwegian sample, 2.2 Measures U.S. sample In addition to basic demographics, the U.S. survey contained items to assess combat exposure, extent of alcohol consumption, avoidance coping tendencies, and psychological hardiness Combat exposure Five questions assessed extent of combat exposure, covering exposure to wounded, killed or dead persons, direct combat engagement, or being in great danger of being killed. These questions came from the U.S. Department of Defense PDHA Post Deployment Health Assessment, a mandatory survey administered to all US military personnel when they return from a deployment (Hoge, Auchterlonie, & Milliken, 2006). Respondents answered No (1) or Yes (2) to indicate whether they were exposed to any of these situations during their deployment. The five item combat exposure scale was created by summing theyes (2) responses. Cronbach s alpha reliability coefficient for this scale was.62 in the present sample Alcohol use Alcohol use was assessed with the AUDIT C (Alcohol Use Disorders Identification Test Consumption; Bradley et al., 2007; Frank et al., 2008). The AUDIT C seeks to identify risky drinking patterns that can lead to more serious conditions. It consists of three items taken from the longer (10 item) AUDIT (Saunders, Aasland, Babor, de le Fuente, & Grant, 1993). AUDIT C items inquire about typical alcohol consumption and are scored from 0 to 4, with high scores indicating greater consumption of alcoholic drinks. For the three item AUDIT C scale, Cronbach s alpha reliability coefficient was.75 in the present sample Avoidance coping Avoidance coping is a maladaptive form of coping in which the individual withdraws and seeks to avoid problems and stressors in life. Avoidance coping was assessed using a 10 item subscale of the Coping Style Questionnaire (Joseph, Williams, & Yule, 1992). Sample items include When facing a difficult situation, I refuse to believe what has happened, and When facing a difficult situation, I work or do other things to take my mind off it. Responses are on a 4 point Likert scale from Not at all to All the time. Cronbach s alpha in the present sample is Hardiness Psychological hardiness was measured with the DRS 15R (Dispositional Resilience Scale), a short, valid, and reliable instrument that has been developed and refined over 25 years (Bartone, 1989; Bartone, 2007). The present study used an updated version of the DRS 15, designed to minimize linguistic and cultural bias (Bartone et al., 2007). This scale shows improved psychometric properties, with confirmatory factor analyses revealing three hardiness facets of commitment, control, and challenge nested under a more general hardiness factor (Hystad, Eid, Johnsen, Laberg, & Bartone, 2010). The DRS 15 includes 15 items, with a 4 point Likert response scale ranging from Not at all true to Completely true. Sample items are Most of my life gets spent doing things that are meaningful and How things go

4 BARTONE ET AL. 501 in life depends on my own actions. Cronbach s alpha coefficient in the present sample is.80. exposure) were mean centered prior to the analysis (Aiken & West, 1991). Age was entered as a covariate in all analyses. 2.3 Measures Norwegian sample Measures for the replication study included basic demographics, extent of alcohol consumption, avoidance coping tendencies, and psychological hardiness. These were closely similar to the measures used in the U.S. survey and are further described below Alcohol use Alcohol use was assessed with the full 10 item AUDIT scale (Saunders et al., 1993). In addition to the three AUDIT C consumption items, the AUDIT includes items that ask about behavioral and mental consequences of heavy drinking, such as How often during the past year have you failed to do the things you should because of drinking? and Have you or someone else been injured as a result of your drinking? Items are scored on a 5 point Likert scale from 0 to 4, with high scores indicating greater alcohol consumption and related problems. For the 10 item AUDIT scale, Cronbach s alpha reliability coefficient was.72 in this sample Avoidance coping Avoidance coping was assessed with the same 10 item scale as used with the U.S. sample, the Avoidance scale of the Coping Style Questionnaire (Joseph, Williams, & Yule, 1992). Sample items include When facing a difficult situation, I refuse to believe what has happened, and When facing a difficult situation, I work or do other things to take my mind off it. Responses are on a 4 point Likert scale from Not at all to All the time. Cronbach s alpha in the present sample is Hardiness Psychological hardiness was measured with an earlier form of the DRS 15. This version contains fewer reverse coded items (four) than the version used with the U.S. sample. The DRS 15 includes 15 items, with a 4 point Likert response scale ranging from Not at all true to Completely true. Sample items are Most of my life gets spent doing things that really pay off, and When I make plans, I am certain I can make them work. Cronbach s alpha coefficient in the present replication sample is Statistical analyses The same statistical procedures were followed for both U.S. and Norwegian samples. Data analyses were performed with SPSS, including PROCESS macros provided by Andrew Hayes (Hayes, 2013). Descriptive statistics were computed for the main study variables and bivariate relations tested with Pearson correlations. First, we evaluated a simple mediation model to assess the potential influence of hardiness on alcohol use and the role of avoidance coping as a mediator in this relation (Hypotheses 1 and 2). Next, we introduced the proposed moderator variable (combat stress exposure) into the model and tested for moderated mediation (Hypothesis 3). Continuous measures involved in the interaction term (hardiness and combat stress Tests of mediation Hypotheses 1 and 2 propose an indirect effects model, where the relationship between hardiness and alcohol abuse is transmitted through avoidance coping. Tests of mediation have traditionally followed the three step approach outlined by Baron and Kenny (1986). Despite its widespread use, this approach is now recognized as inadequate for assessing mediation, on multiple grounds (MacKinnon, Lockwood, Hoffman, West, & Sheets, 2002). For example, the Baron and Kenny approach does not directly address mediation and provides no estimate of effect size (Hayes, 2013). Thus, methodologists now recommend that mediational analyses be based on formal significance tests of the indirect effect ab, as is done, for example, by the Sobel (1982). However, the Sobel test also has its limitations, primarily as it assumes the indirect effect ab is normally distributed, which is often untrue. As noted by Edwards and Lambert (2007), the distribution of ab is nonnormal even if the constituent variables are normal. For this reason, the bootstrap confidence intervals provide a superior test of the significance of indirect effects in mediation models (Hayes, 2013; MacKinnon, Lockwood & Williams, 2004). We, thus, tested our mediation hypotheses using the PROCESS program provided by Hayes (2013). The PROCESS program provides a set of macros for use with SPSS that makes it possible to estimate the indirect effect of ab with bootstrap confidence intervals, under a range of different scenarios. Despite its limitations, we also report Sobel test results as another data reference point Tests of moderated mediation In Hypothesis 3, we predicted that stress exposure would moderate the negative relationship between hardiness and avoidance coping. Assuming the mediation hypothesis is supported (the relation of hardiness to alcohol use is mediated by avoidance coping), it may be that the strength of the indirect effect (mediation) is conditioned by the value of the moderator, stress exposure. This is termed a conditional indirect effect or moderated mediation (Hayes, 2013; Preacher, Rucker, & Hayes, 2007). To test for this, we again used the SPSS macro provided by Hayes (2013), which allows the recommended bootstrap tests to be performed and also provides a number of tools for probing the significance of conditional interaction effects at different levels of the moderator variable. Moderated mediation was tested only in the U.S. data, due to previously described timing limitations in the Norwegian replication sample. As recommended by Preacher et al. (2007) and Hayes (2013), we estimated the conditional indirect effects using ordinary least squares regression and tested these effects with bootstrap confidence intervals, assessing whether the indirect effects differ from zero at various values of the moderator. Using the PROCESS macro for SPSS provided by Hayes (2013), 5,000 bootstrap estimates to generated 95% bias corrected confidence intervals for the observed indirect conditional effects. Conditional indirect effects of hardiness on alcohol abuse (through avoidance coping) were evaluated at five different levels of combat stress exposure, corresponding to the 10th, 25th, 50th, 75th, and 90th percentiles.

5 502 BARTONE ET AL. TABLE 1 Correlations among the main study variables sample 1, U.S. Army unit M (SD) Age Hardiness Combat exposure Avoidance coping AUDIT Age (7.39) Hardiness (5.52) ** Combat exposure 7.58 (1.65) Avoidance coping (4.28) *** *** AUDIT C 4.71 (2.67) *** ** * *** Notes. Ns are shown in italic numbers. AUDIT C = Alcohol Use Disorders Identification Test Consumption; M = mean; SD = standard deviation. *p <.05; **p <.01; ***p < RESULTS Table 1 provides means, standard deviations, and Pearson correlations of the main study variables for the U.S. sample. Here, increased alcohol use is associated with more avoidance coping (.23, p <.001), lower hardiness (.14, p <.01), greater combat exposure (.13, p <.05), and younger age (.19, p <.001). Also, more avoidance coping is linked with greater combat exposure (.18, p <.001) and lower hardiness (.22, p <.001). Hardiness is negatively related to age (.15, p <.01), with younger soldiers showing slightly more hardiness. As shown in Table 2, the same general pattern holds for the Norwegian sample, with one exception. Here, avoidance coping is negatively linked to age (.12, p <.01), with younger soldiers showing more avoidance coping tendencies. Across both samples then, heavier drinking is linked with lower hardiness, providing support for Hypothesis 1. Heavier drinking is also associated with more avoidance coping, and with younger age. Higher hardiness is associated with lower avoidance coping and with younger age. 3.1 Tests of mediation Table 3 presents the regression results testing for mediation in the U.S. sample, and Table 4 shows the similar results for the Norwegian group. Age was included in the model as a covariate. Looking first at sample 1 (U.S.), the total effects model (X Y) shows that hardiness is negatively associated with alcohol use, with a significant unstandardized regression coefficient (B =.085, t = 3.13, p <.01). Central to the mediation hypothesis, the effect of avoidance coping regressed on hardiness (a) is significant (B =.165, t = 3.81, p <.001), as is (b) alcohol use on avoidance coping (B =.136, t = 3.92, p <.001). The Sobel test (assuming a normal distribution) indicates a significant indirect effect (.022, z = 2.69, p <.01). This finding was confirmed by the bootstrap results with 5,000 re samples, with an unstandardized indirect effect of.022 and 95% confidence intervals around this value not containing zero (.045,.008). These results confirm an indirect effect of hardiness on avoidance coping through the mediating variable of avoidance coping. Table 4 shows the comparable results for the Norwegian replication sample. Here, the total effect (X Y) is also significant, showing that hardiness is negatively associated with alcohol use (unstandardized B =.079, t = 1.99, p <.05). The mediation hypothesis is thus confirmed, with a significant effect of avoidance coping regressed on hardiness (B =.155, t = 3.94, p <.001) and also of alcohol use regressed on avoidance coping (B =.176, t = 2.67, p <.01). The Sobel test (assuming a normal distribution) shows a significant indirect effect (.027, z = 2.16, p <.05). This finding was also confirmed by the bootstrap results, with an unstandardized indirect effect of.027 and 95% confidence intervals around this value not containing zero (.069,.005). Figure 2 summarizes the mediation analysis results for both the U.S. and Norwegian samples. 3.2 Tests of moderated mediation The simple mediation analysis yielded evidence of a negative indirect effect of hardiness on alcohol abuse through avoidance coping, with higher hardiness linked to less use of avoidance coping and more avoidance coping related to increased alcohol use. This mediation TABLE 2 Correlations among the main study variables Sample 2, Norwegian Army unit M (SD) Age Hardiness Avoidance coping AUDIT Age 2.15 (.49) Hardiness (5.10) ** Avoidance coping (3.21) ** *** AUDIT 6.00 (3.43) *** ** *** Notes. Ns are shown in italic numbers. Age was only available as a categorical variable, with 1 = 20 and below, 2 = 21 30, and 3 = 31 and above. AUDIT = Alcohol Use Disorders Identification Test; M = mean; SD = standard deviation. *p <.05; **p <.01; ***p <.001

6 BARTONE ET AL. 503 TABLE 3 Ordinary least squares regression results for simple mediation, U.S. sample Variable B SE t p< LLCI ULCI Direct and total effects X M Avoidance (AV) coping regressed on Hardiness M Y Alc regressed on AV coping, controlling for Hardy X Y Alc regressed on Hardy, controlling for AV coping (Direct) X Y Alc regressed on Hardiness (Total) Value SE z p< Indirect effect and significance using normal distribution Sobel M SE LLCI ULCI Effect Bootstrap results for indirect effect Unstandardized Standardized Note. N = 315 U.S. Army sample. Unstandardized regression coefficients are reported unless otherwise noted. Bootstrap sample size = 5,000. Age was included as a covariate. LLCI = lower limit confidence interval 95%; M = mean; SE = standard error; ULCI = upper limit confidence interval 95% (bias corrected bootstrap confidence intervals). TABLE 4 Ordinary least squares regression results for simple mediation, Norwegian sample Variable B SE t p LLCI ULCI Direct and total effects X M Av coping regressed on Hardiness M Y Alc regressed on AV coping, controlling for Hardiness X Y Alc regressed on hardiness controlling for AV coping (direct effect) X Y Alc regressed on hardiness (total effect) Value SE z P Indirect effect and significance using normal distribution Sobel M SE LLCI ULCI Effect Bootstrap results for indirect effect Unstandardized Standardized Note: N = 230 Norwegian Army Sample. Unstandardized regression coefficients are reported unless otherwise noted. Bootstrap sample size = 5,000. Age (categorical) was included as a covariate. LLCI = lower limit confidence interval 95%; M = mean; SE = standard error; ULCI = upper limit confidence interval 95% (bias corrected bootstrap confidence intervals). effect appears fairly robust, holding across U.S. and Norwegian samples. Next, the moderation analysis examined the potential conditional effects moderated mediation of combat stress exposure on this mediation process in the U.S. sample. Results are presented in Table 5 (U.S. sample). Results for the overall model can be seen in the middle portion of the table. A significant indirect effect was found for hardiness on avoidance coping. Combat stress exposure also shows a significant effect, as does the interaction of combat stress exposure with hardiness, which confirms a moderating or conditioning effect of combat exposure. The covariate age was not significant in this model. The lower portion of Table 5 shows the bootstrap indirect effects (Preacher & Hayes, 2004) for the mediating effect of avoidance coping at five different levels of combat stress exposure. The 95% confidence intervals show that the three highest values of combat exposure do not contain zero, whereas the two lower values do (combat exposure values are mean centered). Thus, a moderation effect for combat exposure is confirmed, wherein the mediating effect of avoidance coping in the hardiness alcohol abuse relation is stronger at higher levels of exposure. This interaction effect is illustrated graphically in Figure 3. It is clear from this depiction that the mediation effect of hardiness avoidance coping alcohol abuse is strongest when combat exposure is high and hardiness is low. 4 DISCUSSION Previous studies have focused attention on hardiness and avoidance coping as separate factors that can influence health and performance outcomes (Eid, 2003; Eid & Morgan, 2006; Johnsen, Eid, Laberg, &

7 504 BARTONE ET AL. FIGURE 3 Combat stress exposure moderates the effect of hardiness on avoidance coping in the U.S. soldier sample FIGURE 2 Path coefficients for simple mediation analysis in U.S. (top, N = 315) and Norwegian (bottom, N = 230) samples. Note: Dotted line shows the effect of hardiness on alcohol abuse when avoidance coping is not included as a mediator. a, b, c, and c are unstandardized Ordinary Least Squares regression coefficients. Age was included as a covariate but is not represented here. *p <.05, **p <.01, ***p <.001 Thayer, 2002). The present study contributes to this literature by examining how these variables may interact to influence an important outcome: excessive use of alcohol by soldiers returning from deployment. As posited by our conceptual model, results demonstrate that both psychological hardiness and avoidance coping are linked to alcohol use, with avoidance coping serving as a mediator of the effects of hardiness on drinking levels. Simple mediation analyses confirmed significant indirect effects for avoidance coping in both U.S. and Norwegian samples, suggesting that those who are low in hardiness tend to rely more on avoidance coping strategies, and these tendencies, in turn, can lead to excessive drinking. Increased confidence in the generalizability of this effect is thus justified, as it was replicated across two very different national samples and under somewhat different operational conditions. Whereas for the U.S. soldiers the deployment was for a 12 month wartime mission in Afghanistan, for the Norwegians, it was a 6 month peacekeeping mission in Kosovo, with somewhat different risk conditions. Although dubbed a peacekeeping TABLE 5 Ordinary least squares regression results for conditional indirect effect, U.S. sample Predictor B SE t p< LLCI ULCI Alcohol abuse (AUDIT C) Constant Avoidance coping Hardiness Age [Model R =.33; R 2 =.12; MSE = 6.56; F(3, 311) = 12.64; p <.001] Avoidance coping Constant Hardiness Combat stress Exposure (Stress) Hardiness X Stress interaction [Model R =.29; R 2 =.086; MSE = 16.99; F(4, 310) = 7.30; p <.001] Conditional indirect effect of X on Y at range of values of combat stress exposure Combat stress exposure Boot indirect effect Boot SE Boot LLCI Boot ULCI 10th percentile th percentile th percentile th percentile th percentile Note. N = 315 US Army sample. Unstandardized regression coefficients are reported. Bootstrap sample size = 5,000. Combat stress exposure and hardiness variables are mean centered. Age is a covariate. LLCI = lower limit confidence interval 95%; MSE = mean square error; SE = standard error; ULCI = upper limit confidence interval 95% (bias corrected bootstrap confidence intervals).

8 BARTONE ET AL. 505 operation, there was nevertheless significant danger to the soldiers from land mines, accidents, and fighting among the warring factions (Solberg, Laberg, Johnsen, & Eid, 2005). The replication of the mediation model across these two diverse military samples thus lends further confidence that the effect is not sample dependent. Our conceptual model also proposed that the avoidance coping mediation effect would be conditioned or moderated by levels of stress, in this case, the stress of exposure to combat related events. This was confirmed in the U.S. sample, where it was shown that the mediating effects of avoidance coping in the hardiness alcohol relation are strongest under high stress exposure conditions (Figure 3), thus showing moderated mediation. These findings accord with many studies over the years that have found hardiness operates as a moderator in the stress illness relation, with individuals who are low in hardiness being more vulnerable to stress related health problems (Eschleman et al., 2010; Maddi & Kobasa, 1984). However, the present study is the first to show that this moderation effect operates through the more behavioral variable of avoidance coping. Now that advanced statistical procedures such as conditional process analysis (Hayes, 2013) are readily available for testing a wide range of moderation and mediation effects, future studies should examine the simultaneous and interacting effects of hardiness, avoidance coping, and other variables in the stress health and performance relation. The focus of the present study was on the stressors encountered by soldiers over the course of deployment. However, there is some evidence that past history of traumatic exposure including adverse childhood experiences is more prevalent among military personnel (Blosnich, Dichter, Cerulli, Batten, & Bossarte, 2014). It would thus be good idea for future studies in this area to attempt to control for stressors from sources other than combat exposure. Some limitations of this study should be recognized. Although our findings confirm a mediation effect for avoidance coping in the pathway from low hardiness to alcohol abuse, and a moderating effect of combat stress exposure on this relation in the U.S. sample, this is not sufficient to prove causal directions. The U.S. data are cross sectional, whereas showing causal directionality requires the presumed antecedent variable be measured prior to alcohol use. Nevertheless, the mediation effect observed in the U.S. data was replicated in the Norwegian prospective data, where alcohol use was measured later in time than the other variables. This provides increased confidence that hardiness and avoidance coping really are exerting an influence on alcohol use. Still, the present findings should be viewed as preliminary until confirmed with longitudinal data. It is also the case that hardiness and avoidance coping were measured at the same time point in both samples, whereas ideally, avoidance coping should be measured after hardiness in order to demonstrate a clear causal sequence. But given that hardiness is a relatively stable personality trait as compared with coping strategies that are more changeable, it seems unlikely that avoidance coping actions would cause hardiness levels to decline (Hystad, Olsen, Espevik & Säfvenbom, 2015). Another possible limitation relates to the slightly different scales used across the two samples. To measure alcohol use, the full AUDIT was used in the Norwegian sample, whereas the shorter AUDIT C was used in the U.S. sample due to space limitations. However, these scales have been shown to be highly similar in terms of sensitivity and specificity for identifying alcohol problems (Caviness et al., 2009). Also, considering that 5 of the 10 AUDIT items (items 4 8) ask the respondent to refer to a time frame of the past year, it is possible that responses to this measure may reflect past alcohol problems more so than current ones. This is not considered a serious limitation, given the many studies confirming the AUDIT is a valid measure of current alcohol related problems (e.g., Bradley et al., 2007; Daeppen, Yersin, Landry, Pécoud, & Decrey, 2000; Saunders et al., 1993). Finally, both samples examined here were composed primarily of men, and so results may not be applicable to women. Future studies should attempt to evaluate the observed effects in comparable samples of women. 4.1 Implications for prevention/treatment Excessive alcohol consumption is a common problem among military personnel returning from deployment. By providing a better understanding of the various factors that contribute to alcohol abuse in this population and how they interact, studies like the present one can inform more effective prevention and screening programs. Early recognition of those at highest risk for alcohol abuse is important so that preventive interventions can be offered. The current exploratory study identifies stress exposure, hardiness, and avoidance coping as factors that can influence alcohol abuse in this population and shows how they may interact in this process. Although further studies are needed to confirm these relations, results are potentially important for facilitating early identification of those at high risk excessive alcohol use. Current screening approaches in the U.S. military fail to identify many cases at risk for alcohol and other mental health problems (Hoge et al., 2006). Screening tools that rely on self reports of drinking behavior can yield many false negatives, for several reasons. For one thing, soldiers worry that admitting to a drinking problem could damage their promotion chances, or have other negative consequences. Also, many young people with a drinking problem fail to recognize it as such Monti, Tevyaw, and Borsari (2005). By incorporating measures of avoidance coping and hardiness, screening programs can identify more individuals who are at risk for alcohol abuse, but who may not recognize it in themselves or be willing to admit it openly. These higher risk individuals could then be offered special support and training programs aimed at increasing active, problem focused coping skills and hardiness attitudes (Bartone, Eid, & Hystad, 2016). Such training programs could also be implemented as early prevention strategies prior to deployment, and even during deployment if operational conditions permit. Another approach to increasing stress resistance in employees would focus on creating more positive workplace environments (Grawitch, Ballard, & Erb, 2014). As described by Bartone (2006), organizational policies and practices and leader actions can have an enhancing effect on workers sense of commitment, control, and challenge, the three primary hardiness facets. For example, by involving employees more in decision making and providing ample information and recognition, organizations can increase the sense of commitment and control across the entire workforce. Likewise, leaders who treat failure as a chance to learn, rather than something to be berated or punished, help to build a sense of challenge and positive growth in employees. Similar recommendations are offered by Grawitch et al. (2014), who see an

9 506 BARTONE ET AL. organizational focus on employee involvement, recognition, and growth as important for creating psychologically healthy workplaces in which workers are more resistant to the ill effects of stress. 5 CONCLUSION This study finds that increased alcohol consumption following stressful military deployments is related to lower levels of psychological hardiness in U.S. and Norwegian military samples, and this relation is mediated by avoidance coping tendencies. In the U.S. sample, this mediation effect is stronger for soldiers who experienced greater stress exposure (moderated mediation). Although further longitudinal studies are needed to confirm these results, the findings are suggestive that screening and treatment programs can be improved by including hardiness and avoidance coping measures in post deployment assessments. 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Substance use and substance use disorders in recently deployed and never deployed soldiers. Drug and Alcohol Dependence, 134, How to cite this article: Bartone PT, Johnsen BH, Eid J, Hystad SW, Laberg JC. Hardiness, avoidance coping, and alcohol consumption in war veterans: A moderated mediation study. Stress and Health. 2017;33: /smi.2734