Accepted on 16 Nov 2019
Submitted on 08 Apr 2019
There are approximately 20 million veterans living in the United States today (U.S. Department of Veterans Affairs, 2018a). The military conflicts of the Post 9/11 era, such as Operation Iraqi Freedom and Operation Enduring Freedom, increased combat operations and subsequently grew the size of the military, resulting in the largest surge of reintegrating veterans in recent history. The transition from active duty to veteran status often requires service members to move from certainty, routine, community, and a sense of purpose to uncertainty. Reintegrating veterans are vulnerable to social isolation, anxiety, depression, and exacerbations of post-traumatic stress. In comparison to their civilian peers, veterans of these Post 9/11 conflicts experience elevated rates of mental illness and suicide (U.S. Department of Veterans Affairs, 2016). However, struggles with mental health are not unique to newly reintegrating veterans alone. Veterans of prior conflicts also experience a high burden of mental illness (U.S. Department of Veterans Affairs, 2016). For example, in a 2015 assessment of Vietnam veterans, 11.2% had a diagnosis of Post-Traumatic Stress Disorder (PTSD), 36.7% had a diagnosis of major depression, and 2.2% struggled with alcohol abuse (Marmar et al., 2015). Further, in 2016, approximately 65% of all veterans who died by suicide were older than 50 years (U.S. Department of Veterans Affairs, 2016). Moreover, approximately 20 veterans of all conflicts die from suicide each day (U.S. Department of Veterans Affairs, 2018b). According to the Veterans Affairs (2017), suicide risk was 22 percent higher among veterans when compared to their civilian counterparts (after adjusting for the difference in age and sex).
The United States Department of Veterans Affairs (VA), academic institutions, and healthcare and community organizations are developing strategies to address this mental health crisis. The U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, and the National Action Alliance for Suicide Prevention (2012) determined that research should address suicidal ideation and behavior among vulnerable populations in order to ensure the best outcomes. A 2010 literature review identified a lack of sufficient data regarding the effectiveness of suicide prevention efforts for veterans, demonstrating a critical need for additional investigation (Bagley, Munjas, & Shekelle 2010). Approximately 60% of veterans who are at risk for mental illness and suicide do not access mental health resources (Hoge et al., 2004; Kehle et al., 2010). Veterans are often hesitant to seek assistance, most often due to stigma and cost barriers (Tsai, Mota, & Pietrzak, 2015). As such, identification of existing protective factors is critical to developing methods that will be utilized by veterans. The assimilation of insight from veterans and their communities will be critical to this process. When protective factors that halt suicidality are identified, development of interventions for future research can progress.
The Veteran’s Suicide Protection Advisory Group (VSPAG) was formed as a veteran-community engagement project to identify existing protective factors for suicide. Community engagement is the process of engaging key stakeholders in addressing issues that are important to them (Mullins, Abdulhalim, & Lavallee, 2012; Frank, Basch, & Selby, 2014). Community engagement activities, such as gatherings and town halls, provide platforms for invested parties to have an active voice. Innovative community engagement approaches hold the potential to generate socially relevant and applicable research findings (Flynn, Krause-Parello et al., 2019). These methods can establish partnerships around significant clinical and social problems, such as community prevention of veteran suicide, that have not been effectively addressed by traditional randomized controlled trial (RCT) designs. There is evidence that the impact of community engagement strategies improves the adoption and acceptance of interventions used in RCTs (Johnson et al., 2018). This may include the identification of effective mental health treatment in community-based settings. Stakeholder engagement in development of solutions provides a model that encourages self-determination and advancement of policy-based, holistic solutions that are more acceptable to those in need of care (Cox et al., 2014).
Prior to the commencement of this project there was no community-based infrastructure found supporting stakeholder engagement with this particular objective. VSPAG’s primary purpose was to generate knowledge via discussion and collaboration among veterans, veterans’ friends and family, employers, service providers, researchers, policymakers, and advocacy groups about suicide protective factors. The project was conducted over a period of 33 months and consisted of three sequential tiers see Figure 1) of community engagement.
Tier Building.
Over 70 stakeholders were engaged in total. Participants were recruited via word of mouth, outreach to community organizations, and social media. Each tier of this project was reviewed and approved by a university institutional review board. The geographic scope for the project included Denver, Arapahoe, El Paso, and Larimer Counties in Colorado due to the concentration of veteran populations and distance to meeting location. Minutes were taken at all meetings and verified by the groups at the conclusion of each meeting throughout the project.
Over the first two months of the Tier-I phase, which began May 2015, community stakeholders were invited to attend monthly discussion groups. The project was publicized via word of mouth as well as flyers, social media, and email invitations. Meetings were hosted in the community and at the university’s student union.
The administrative team, consisting of Project Lead, Co-Lead, and Project Manager, also joined the stakeholders at community events throughout the first two months engaging and informing others about the project. These events included the local Veterans of Foreign Wars (VFW) Health Fair, University Block Party, local VFW Golfing Tournament, and a Veterans Day 5K Run.
In months three to five, three distinct discussion groups were formed: 1) veterans, 2) friends and family, and 3) service providers. An identified stakeholder, known as the Partnership Team Member (PTM), led each group. PTMs remained consistent throughout Tier I and they were responsible for assisting with meeting arrangements and engagement efforts for their respective group. Stakeholder groups met separately on a monthly basis to gather and prioritize information specific to each group (see Table 1).
Table 1
Community Engagement meetings rosters.
| Discussion Groups | Community Engagement Meeting 1 # of attendees | Date of meeting and time | Community Engagement Meeting 2 # of attendees | Date of meeting, and time | Community Engagement Meeting 3 # of attendees | Date of meeting and time |
|---|---|---|---|---|---|---|
| Veterans only | 8 | 7/23/15 Evening | 6 | 8/24/15 Evening | 8 | 9/24/15 Evening |
| Veterans’ Friends and Family | 6 | 7/21/15 Evening | 4 | 8/25/15 Afternoon | 6 | 9/22/15 Evening |
| Veterans’ Service Providers | 8 | 7/20/15 Evening | 7 | 8/25/15 Evening | 7 | 9/21/15 Evening |
Each group had a maximum of 8 stakeholders in attendance and was comprised of individuals of different backgrounds, experiences, sex, and age. Attendance was not mandatory for all three meetings and contributors changed from meeting to meeting. Those in attendance received a meal, gift card from a retail chain, and a parking voucher.
In months 6–8, the groups merged to form the Executive Partnership Team (EPT). The EPT met bi-monthly, 6 meetings total, with 8–14 stakeholders in attendance per meeting. Those in attendance received a meal, a gift card from a retail chain, and a parking voucher.
After the completion of the EPT bi-monthly meetings, the Project Leads, PTMs, and Project Manager compiled a sample of suggested stakeholders to serve on the VSPAG (N = 10). The identified stakeholders were notified to determine interest and availability.
Once the VSPAG was formed they met in January 2016 to define directions of interest for the upcoming Tier II phase. To prepare for Tier II the VSPAG developed comparative effectiveness research (CER) questions. The VSPAG identified the following questions at this meeting:
At the conclusion of Tier I, the Project Leads sponsored a VSPAG Appreciation Dinner for the veterans and stakeholders to formally bridge between Tiers I and II and to thank all stakeholders for their investment in the project.
Throughout Tier II, VSPAG included 10 members who attended 7 in-person meetings held in May 2016 through May 2017. Attendance at the meetings was as follows: May (N = 10 attendees), June (N = 10 attendees), July (N = 8 attendees), August (N = 7 attendees), October (N = 5 attendees), December (N = 6 attendees), February (N = 6 attendees), and April (N = 6 attendees).
The meeting focus evolved organically from general veteran mental health and personal experience to protective factors for suicide in the veteran community. These meetings explored the topic of suicidal ideation, including how it emerges and is managed individually and systemically, as well as existing factors that may possibly protect against ideation and impulsivity. Those in attendance received a meal and a parking voucher.
In September, November, January, and March, VSPAG members participated in enrichment activities including face-to-face and virtual conference meetings, a mental health first aid course, a national suicide prevention conference, research webinars, and community networking events. An equine facility visit inspired an interest in peer-to-peer activities and service animals as protective factors for suicide.
In May, VSPAG hosted a town hall meeting at the local VFW. At this event, the group introduced the community engagement project using a panel format. The audience was encouraged to ask questions and express opinions and observations in order to engage attendees and generate ideas. There were over 19 stakeholders in attendance.
To culminate Tier II, the Project Leads and VSPAG members developed a conference abstract and submitted for peer review to the American Association of Suicidology (AAS). The title of the abstract was Collaboration in veteran suicide protection: Engaging community perspective to develop comparative effectiveness research.
In Tier III VSPAG continued face-to-face and virtual meetings. All in-person meetings were held at the university’s student union. Those in attendance received a meal and a parking voucher. During this tier, VSPAG members began engagement activities to formulate a research question based on the work of the prior tiers. The Project Leads initiated a conversation regarding the basic principles of research design and methodology. VSPAG also participated in research-oriented webinars, a grant-writing workshop, and a writers’ retreat. At the conclusion of Tier III, VSPAG developed a CER research question for further exploration.
The group elected to develop a manuscript outlining this community engagement project. The manuscript activity began with the identification of potential peer-reviewed journals for submission. The Project Leads and Project Manager provided a list of potential journals and journals’ guidelines for authorship to the VSPAG that focused on mental health, veteran population, and suicide prevention for consideration. The writing of the manuscript began with the writers’ retreat, which took place in the spring of 2018 in a conference room at the university’s student union. To maximize time and effort, sections of the manuscript (e.g. introduction, background, methods, outcomes, etc.) were assigned to small groups of VSPAG as well as the Project Leads. Individual iPads were distributed to each of the VSPAG members for use during the activity. At the end of the retreat, the sections were turned in to the Project Leads for synthesis and journal formatting. A meal and parking voucher were provided to attendees.
The outcome of Tier I included a basic discussion involving mental health and personal experience. Participants described the focus as “information gathering” regarding two topics: effective and ineffective approaches for suicide protection used by the veterans in the community, as well as identification of the core group of stakeholders who were suited to engage in the second and third tiers of the project. This tier brought together individuals who could openly share their ideas on suicide protective factors in a constructive way. Rotating participants were valued as a means to generate new ideas; however, some participants who attended all sessions felt that inconsistency in participants from session to session contributed to a lack of focus and impeded the development of group solidarity.
The stakeholders were separated into three different groups and asked “what do you believe protects veterans from suicidal action?”
Veteran answers:
Friends and family answers:
Service provider answers:
Broadly, the dialogue addressed a series of institutional, community, and personal factors that stakeholders felt protected veterans from suicide, The topics generated by each group correspond closely to the existential therapeutic group factors identified by Yallom (2005) as altruism, instillation of hope, imparting information, socializing techniques, imitative behavior, cohesiveness, catharsis, and self-understanding.
VSPAG acknowledged that the relationship-building activities in Tier II promoted a safe and energetic environment for open, honest dialogue and collaboration. VSPAG expressed that veteran-centered, trauma-informed care was not readily available and that protective interventions for suicide should ideally be developed from veteran experiences. Topics explored included variations in coping mechanisms by generation, barriers to care, assorted treatment modalities, and the likelihood that the veteran community would embrace various methods. VSPAG discussed yoga, social media, service animals, peer-to-peer support, professional mental health services, and peer-to-peer activities and service animals as potential protective interventions for suicide.
The VSPAG initiated a discussion regarding possible CER priorities: efficacy of non-clinical peer-to-peer mentoring during specific transition time periods vs. veterans with no mentoring intervention; service dog ownership or training intervention vs. cognitive-behavioral therapy (CBT); and inclusion of families into reintegration strategies vs. no specific family reintegration strategy.
In addition, the abstract submitted in this tier was accepted by the AAS Annual Conference for a podium presentation. The VSPAG selected a member to present at the AAS conference with the Project Leads in 2017 in Phoenix, Arizona.
In Tier III, activities were devoted to the development of a tangible product. The VSPAG members were active and equal partners in all project deliverables. Activities were devoted to the development of CER research questions. The research priorities on protective factors for veterans’ suicide identified by VSPAG are listed in Table 2.
Table 2
Research priorities on protective factors for veterans’ suicide identified by VSPAG.
| Programs facilitating veteran-to-veteran peer assistance |
| Social media assistance and connection |
| Progressive changes in Veterans of Foreign Wars operations |
| Family support |
| Mind-body interventions (e.g. yoga, martial arts) |
| Therapeutic expression in the arts |
| Access to highly trained service dogs |
| Equine therapy |
| Access to medical marijuana |
| The effects of educational structure |
| Educational counseling services |
* VSPAG = Veteran’s Suicide Protection Advisory Group.
The group determined over multiple discussions that the research question should evaluate the effectiveness of peer-to-peer support vs. peer to peer support with service animal interaction as an added component. The VSPAG also decided to develop a manuscript to summarize the outcomes of the tiers and a CER to develop a formal research proposal.
As Tier III progressed, stakeholders voiced satisfaction with the veteran-driven infrastructure of this project. As one participant stated, “the process of establishing structure and goals through multi-tiered levels gave us a balanced peer group and the focus to identify an area of research needed to further the development of interventions.” Participants identified the active, collaborative support and defined the purpose of the advisory group itself as an example of suicide protective factors. This engagement project revealed the strong desire within the veteran-based community to contribute and collaborate with one another as well as with members of the academic research team.
The VSPAG generated CER research questions and decided which had the greatest potential for accuracy, veteran-community benefit, and interest. VSPAG decided based on the topics generated in the previous two tiers that the CER question for suicide protection should be based on evaluating the effectiveness of peer-to-peer support vs. peer to peer support with service animal interaction/training.
This community engagement approach connected veterans and key community stakeholders on a sensitive topic and included a multitude of activities (see Table 3). Veteran perspectives were explored and factors that are protective for suicide in veterans were uncovered. The project provided a safe atmosphere that allowed for an authentic, honest dialogue on the epidemic of veteran suicide and protective factors that bond veterans to society and well-being.
Table 3
Community Engagement Activities.
| Activity | n |
|---|---|
| Mental Health First Aid | 1 |
| Equine Programs for Veterans | 2 |
| National suicide presentation conference presentation | 1 |
| Local suicide prevention conference attendance | 1 |
| Town Hall-VFW Post 1 | 1 |
| Writers’ Retreat | 1 |
| VSPAG Appreciation Dinner | 1 |
Key: VFW = Veterans of Foreign War; VSPAG = Veteran’s Suicide Protection Advisory Group.
The U.S. Department of Veterans Affairs (2018a) reports that there are over 20 million veterans in the U.S. and an increasing rate of mental health problems among them (Marmar et al., 2015). This community engagement project identifies interventions that are protective factors for suicide. A variety of nontraditional protective factors were identified by a cohort of highly engaged veteran-centered community members. Protective factors included community commitments, service animals, family, and societal support, social media, technology, peer groups, and complementary and integrative approaches such as yoga and art. Discussion group consensus indicated that the action of caring for others and obligations to social relationships and meaningful activities gives veterans a sense of purpose and belonging that often times is missing since military discharge. Protective factors for suicide may help restore roles and values that the military instills into the veterans, including structure, identity, responsibility, purpose, unity, and belonging.
The protective factor of greatest interest to many of the VSPAG was a service dog. In a recent review of the literature, canine assistance was found to enhance mental and physical well-being in veterans with PTSD (Krause-Parello, Sarni, Padden, 2016). A service dog is trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other disability (Brennan & Nguyen, 2014). Despite the protective qualities service animals provided to veterans in this project, there is a lack of research on the efficacy of service dogs for veterans.
In summary, the formation of VSPAG identified a range of protective factors for suicide. The VSPAG used three tiers of veteran-stakeholder engagement to identify potential research topics on the protective factors for suicide in order to address the needs of this vulnerable population.
What we learned from this project is that despite a difficult topic such as suicide, the veteran community wants to engage in dialogue, have their voices heard, and share and find new solutions to keep veterans from going down a dark road and taking their lives. Moving forward, identified protective factors gleaned from this multi-tier project are for the most part not associated with traditional clinical treatment methodologies for suicidality. Many remain untested and lack clinical evidence. The outcomes of this community engagement project identified methods that should be tested with RCTs. Understanding, evaluating, and disseminating promising community-based interventions may lead to meaningful reductions in the burdens of mental illness and suicide in veteran populations. One veteran’s life lost to suicide is one too many. Together we can make a difference.
The Project Lead Dr. Krause-Parello and Co-Lead Dr. Rice thanks the Veteran Suicide Advisory Group (VSPAG) members many who co-authored this paper and Marla Hinners, Glenda Nash Buscarello, Heidi Tyrrell, and other VSPAG members who played a key role in the project’s success. We also thank the Project Managers Ms. Eleni Padden (Tiers I & II) and Ms. Blanchard (Tier III). The Project Leads and VSPAG also acknowledge all of the key community stakeholders who participated in this multi-tiered veteran-centered community engagement project.
This project was partially funded through a Patient-Centered Outcomes Research Institute (PCORI) Pipeline-to-Proposal Award 3406820, administered on behalf of PCORI by Trailhead Institute.
The authors have no competing interests to declare.
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