To honor and recognize the diverse group of stakeholders who interact with the VA healthcare system.
Through many lenses (e.g., bench science, social-behavioral research, implementation science, program evaluation, health services research, etc.), veterans studies researchers seek to understand and accurately represent the complexities and nuances of the veteran experience. Veteran community-engaged research (CEnR) is a valuable emerging methodological approach in this endeavor. By collaborating with veteran communities (i.e., veterans, their families and caregivers, and members of the community in which veterans live) at all stages of the research process, veterans studies researchers can ensure that research findings are meaningful to the lives of their proposed beneficiaries (Franco et al., 2021). They can also ensure that veteran services are acceptable, accessible, and useful to their intended populations (Gagliardi et al., 2015).
The purpose of this article is to illustrate the valuable application of veteran CEnR to the development of a US Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) research agenda that addresses veteran community reintegration. Community reintegration is a historically broad and nuanced subject that involves resuming roles in one’s community of choice. Veteran CEnR has been especially informative in this field of inquiry (Ali et al., 2019; DeVoe et al., 2012; Dobson et al., 2021; Elnitsky et al., 2017; True et al., 2021). In keeping with the ideals of CEnR, this article is a collaboration between researchers on the Enhancing Veteran Community Reintegration Research (ENCORE) team and its veteran community partners, referred to later as the multi-stakeholder partnership (MSP). The veteran CEnR approach that guides the ENCORE project was used to involve partners in this dissemination work. Because dissemination efforts—especially peer-reviewed publications—often exclude collaboration with partners, the methods used to write with MSP co-authors are described to guide researchers who may want to replicate or build from this process.
Many researchers at the VA Veterans Health Administration value veteran CEnR because their work is often directly applied to the development of products and services used by the 9.7 million unique veterans enrolled in the VA system of care, each with their own preferences, needs, and viewpoints (Atkins et al., 2016; Besterman-Dahan et al., 2018, 2021; Brown et al., 2016; Crocker et al., 2014; Hahm et al., 2021; Hamilton & True, 2016; Hyde et al., 2018; Luger et al., 2020; Matthieu et al., 2016; Melillo et al., 2019; True et al., 2021).
In designing this project, the ENCORE team began from the assumption that tackling an issue as nuanced as veteran community reintegration would require involving veterans, their families, and communities of choice. Thus, the MSP was formed on the principles of CEnR, which “involves establishing and maintaining authentic partnerships between researchers and those who are being researched, including local community members and organizations” (Luger et al., 2020, p. 495). MSPs are formal partnerships of representatives from diverse sectors, professions, and disciplines. MSPs are characterized by: (a) diversity of perspectives, (b) a goal of mutual benefit, (c) decentralized decision-making, and (c) achieving goals that no one group could achieve independently (MacDonald et al., 2019; Sloan & Oliver, 2013). The ENCORE MSP is a space where stakeholders collaborate and reach consensus about veteran community reintegration research priorities. It exists to ensure that future VA research findings can support veteran community reintegration services that are designed and delivered with a deep understanding of veterans’ social and cultural identities.
Seven MSP members’ autobiographical accounts and first-hand narratives drove the development of this paper. They describe the organization, functioning, and outcomes of the MSP through accounts of their personal experiences. These narratives work together to illustrate the value of veteran CEnR as an emerging methodological approach in VA research post-9/11. Narratives encourage readers to recognize that CEnR can ensure that (a) research is designed with service to and advocacy for the veteran community in mind; (b) research is driven by a diversity of experiences, such as those represented by the MSP; and (c) trust is built between veteran communities and the VA. In the future we hope veteran community engagement is the root from which all veteran research stems.
The quote that begins this introduction comes from the following narrative, written by MSP member Chris Brown and presented in its entirety. His narrative describes the multiple ways in which he interacts with the VA healthcare system—as patient, community partner, and provider—and how he draws from each of those perspectives when working with the MSP. This narrative was selected to introduce the paper because it describes the fundamental goal and merit of veteran CEnR—authentic stakeholder engagement that “honors and recognizes” the expertise in experience, thereby democratizing the research process.
I am a disabled combat veteran of Iraq and Afghanistan, who served in the Marine Corps from 2004 to 2008 and I received a Purple Heart for being wounded in action. I am the founder of Growing Veterans, a community nonprofit, established in 2012, that uses farming as a catalyst for community reintegration and peer-support. I have worked at a VA Vet Center for the past 6 years as a clinical social worker and PTSD specialist who provides counseling to veterans, most of whom have endured trauma. When it comes to interacting with the VA, I have multiple perspectives to share.
Joining the ENCORE multi-stakeholder panel was an opportunity to distill my various interactions with the VA into insights that could enact meaningful change. Being able to offer my experience and expertise as a patient, community partner, and provider has given me the chance to reflect and understand how stakeholders interact with the VA, where gaps in services and research exist, and explore solutions with colleagues about those areas that need improvement. I was impressed to learn the diverse depth and breadth of knowledge that exists among the multi-stakeholder panel.
If it takes 17 years for research to result in actual changes in health practice, those changes certainly ought to be informed in large part by the stakeholders who will be impacted by those changes. Engagement with stakeholders in the research and development process can provide timely and valuable recommendations, especially if done in a way that honors and recognizes the diverse group of voices that make up the multitude of stakeholders who interact with the VA healthcare system. By engaging a widely diverse multi-stakeholder panel, ENCORE can enrich their understanding of problems that need further research in ways that wouldn’t happen otherwise. This bottom-up approach to understanding and informing research is indicative of a research team that is highly skilled in their craft and innovating new and effective ways to identify problems, drive research, and inform future policy. Having participated first-hand in this type of engaged and thoughtful research I believe this bottom-up approach should become the new standard of research and development throughout the VA health care system.
In his narrative, Chris describes the decentralized decision-making that characterizes the MSP (MacDonald et al., 2019; Sloan & Oliver, 2013). He explains that this approach serves to “enrich [scientists’] understanding of problems that need further research in ways that wouldn’t happen otherwise.” Here, he hits on an important function of veteran CEnR: engaging veteran communities in the research process helps curb researchers’ implicit biases that can reduce the impact and practical application of findings (Ali et al., 2019). Throughout this article, readers will have the opportunity to situate ENCORE’s approach to veteran CEnR within the biographical contexts of veteran community and MSP members.
The ENCORE MSP currently includes 25 active members. Five members are veterans and their families and caregivers; five members are from community organizations that serve veterans; five members are established researchers from inside and outside of the VA who study veteran community reintegration; and 10 members are from various VA program offices, many of whom help determine the directions of VA policy. Several MSP members occupy space in two or more of these communities (e.g., veteran and community organization). Seven members of the MSP volunteered to write narratives for this article. MSP volunteers had varying levels of experience writing peer-reviewed publications ranging from none to regularly authoring scientific articles. The ENCORE team drew from writing center pedagogy of inclusion to develop an approach that could engage diverse MSP members (Barnett & Blumner, 2008; Blazer, 2015; Monty, 2016). Writing center practice begins from a collaborative mindset, so each MSP volunteer was paired with a writing partner from the ENCORE team.
To support the writing process and limit burden to our collaborators (e.g., need for additional time commitment), the ENCORE team developed a writing prompt to which MSP members could react:
“In the space below, write a 250–500-word narrative about why you joined ENCORE’s multi-stakeholder panel (MSP) and what it means for you to be part of a diverse team, driving change at the VA.”
MSP volunteers had one month to draft their narratives and meet with their writing partners to discuss the primary purpose and goals of their writing. ENCORE writing partners focused on the big ideas posed in each narrative from the perspective of a curious reader rather than copy editing and grammar. Writing partners listened and posed questions to better understand the writers’ goals, values, and points of view. Writing partners made suggestions for bringing those understandings to the forefront of the writing. MSP volunteers chose whether to edit their narratives before finalizing their writing for inclusion in the publication.
At the start of the writing process, the ENCORE team wanted to engage stakeholders to write about the value of veteran CEnR as an emerging methodological approach in veterans studies. However, the MSP’s narratives primarily drove the structure and focus of the article. The MSP narratives presented herein have been shortened to manage the length and flow of the paper but have not been edited by the ENCORE team. Complete versions of each narrative are included the Appendix. Shortened narratives are included in the sections of the paper that align with their underlying messages.
If you change what you do, you will change who you are.
The ENCORE project was established by the VA to use veteran and stakeholder engagement to develop a research agenda that improves the impact of veteran community reintegration research. ENCORE is a product of VA’s movement toward veteran-centric services, including research. In the last two decades the VA became keenly interested in the “veteran voice,” asking veterans what they want and need from the organization and approaching them as partners in their care. Concurrently, clinical and health services researchers at the VA began to prioritize use of veteran CEnR designs such as action research, community based participatory research, patient-centered research, human-centered design, and user experience research (Atkins et al., 2016).
Use of CEnR approaches in VA research gained traction during the last two decades as CEnR became more commonplace in health services research (True et al., 2021). However, adoption increased beginning in 2015 when David Atkins, Director of HSR&D, instituted organizational structures and systems that promote veteran community engagement in VA research. Dr. Atkins convened a Veteran Engagement Workgroup to fill a gap:
while as a healthcare system we [the VA] have a strong mission to serve the veteran and have been spending a lot of time over the last several years thinking about how to put the patient at the center of the care experience, that voice is often missing from our research endeavors … without knowing [veterans’] experiences … the solutions we develop may not meet the values and needs of the patients. (Atkins et al., 2016, 06:15:00)
The goals of the Veteran Engagement Workgroup were to improve the design of veteran-relevant research, increase uptake of research into practice, build veteran support for research, and restore trust in the VA (Atkins et al., 2016).
The work of this group resulted in the codification and diffusion of Veteran CEnR at the VA. First, all VA funded research centers must organize a Veteran Engagement Group (VEG). There are currently 17 VEGs working within VAs nationally. A VEG is comprised of veterans who work with VA researchers at all stages of the research process to increase the impact and relevance of research for veterans. These VEGs critically ensure that recipients of VA grant funds will carry out this part of the organization’s mission. Second, the VA published the Strengthening Excellence in Research through Veteran Engagement (SERVE) Toolkit to help VA researchers “include veterans and other stakeholders in the development, implementation, and dissemination of research studies” (Hyde et al., 2018, p. i). Third, the VA’s Office of Rural Health funded the establishment of a Center for Growing Rural Outreach through Veteran Engagement (GROVE) to develop “capacity and resources for VA researchers and staff to be more inclusive of rural veteran populations and to serve as a resource center to support projects interested in including veteran engagement in their methods” (Health Services Research & Development Service, 2021, Introduction).
The following partial narrative, written by Monica Matthieu is the personal account of a VA community reintegration researcher who is a member of the MSP. It situates the VA’s journey toward veteran CEnR within the autobiographical memory of her vocational trajectory. Monica’s narrative was selected to accompany this section because she draws lines between her own efforts and the VA’s efforts to engage veterans “across the research continuum.” Monica describes her research with veterans as a form of advocacy, a way to serve veterans like her father through her “vocation”—a word she deliberately chooses to describe, not a job or a career, but “a call to serve.” In this way, Monica’s narrative also illustrates that veteran CEnR creates space for service and advocacy in research, something that other methods do not achieve (Dobson et al., 2021; True et al., 2021).
I have a few “Monica-isms.” Things that as a Southern woman, I say over and over again, talking very fast, very loud, very animated, and with hand gestures. Things like, “If you want to change the VA, don’t complain from the outside, go work for the VA and change it from within.” “If you change what you do, you will change who you are.” I get to impose these isms (and more) on the student veterans and civilians, that I am so honored to teach as faculty at the Saint Louis University School of Social Work. Besides the isms, I share the stories of how I found my vocation, not a job in the VA or a career in social work, a response to a call to serve. I tell my students, “I did not serve in uniform; I choose to serve in a different way, in VA.” I answered a different call, one that allows me to be the proud daughter of an Army draftee, who still believes she can change the system from within and make a difference for the veterans like my Dad.
In 2011 I was recruited to work with the Mental Health QUERI (Quality Enhancement Research Initiative) and create a modern twist on the Mental Health Stakeholder Council to serve as a partnered group of key stakeholders that would provide insight and feedback on research conducted by the MH QUERI across the research continuum (Matthieu et al., 2016). A small group of veterans on staff joined with our community partner as the chair of the Council and myself to develop and implement my first veteran, staff, and provider engagement group, one that proudly continues to this day. A few years later, I was asked to support the planning of a second veteran engagement group, this one for our HSR&D Center of Innovation (COIN) to be fully staffed by veterans. Interesting twist, but same mission, involve veterans in the design and dissemination of our research. But now it was a VA requirement to have a veteran engagement group.
From the build and sustainment of these two groups nearly 7 years later, I have learned what veteran engagement is not. It is not presenting “Grand Rounds” on our research projects that are about to be published to share our findings. It is not hosting a “Research Day” to share how great our innovations are that they have never heard about. It is not telling them how many patents the VA has or the research that has won special prizes. It is none of that. It is, how does what I believe in, and study, touch their lives and make a difference?
Veteran engagement is engaging veterans IN research. It is teaching them as colleagues about the research process, the ways to get involved in research, the opportunities to serve as consultants on projects, mentoring them on the pathway to becoming a Principal Investigator if that is their goal. It is listening to their stories, hearing beyond the words, and then harnessing their passion to right a wrong, to invent a solution, to charge up a hill to make a difference in the lives of the veterans to the left and to the right of them. It is about partnering and partnering well.
Veteran engagement to me is about letting them in, being loyal, consistent, and true, listening carefully, and in the end, if you have a servant heart, veterans will teach you a thing or two about research. Let veterans in. Listen. Engage. Learn.
Monica’s narrative describes how her application of veteran CEnR changed following HSR&D’s institutionalization of this approach. She also explains how her understanding of veteran CEnR has formed over the course of her career, citing what is and is not veteran CEnR. For Monica, veteran CEnR is an extension of service and advocacy on the part of the researcher and on the part of the community partner because it requires both parties to first, identify pressing problems affecting the veteran community and then, commit to “right a wrong, to invent a solution” that honors the experience and values of that community. This illustrates the goal of reciprocity or mutual benefit that characterizes MSPs (MacDonald et al., 2019; Sloan & Oliver, 2013).
Real change happens by working collaboratively across sectors, professions and disciplines with support and intention.
Much of the public’s understanding of the veteran experience is formed by media outlets and government officials. These entities often draw from research findings to form public narratives about this heterogeneous population and its priorities. Thus, researchers and the organizations that fund research help shape public understandings of what veterans want and need when they decide which questions to ask, how to ask those questions, and which results to share. Therefore, veterans must be “authentically engaged” in research. Authentic engagement includes stakeholders as full partners in setting research priorities, forming research questions, and shaping the design, funding, conduct, and dissemination of studies (Woolf et al., 2016). The impact of authentic stakeholder engagement is so substantial that the Institute of Medicine (IOM), Agency for Healthcare Research and Quality’s (AHRQ), James Lind Alliance (JLA), and Patient Centered Outcomes Research Institute (PCORI) have all developed frameworks for systematically engaging stakeholders in research, from topic generation to dissemination of results (Cowan & Oliver, 2021; Haynes et al., 2018; Institute of Medicine (US) Committee on Quality of Health Care in America, 2001; Nass et al., 2012; Whitlock et al., 2010).
The ENCORE team found that veteran communities are most often engaged by researchers when forming questions, conducting, and disseminating research. Less often, veteran communities help set research priorities. In developing ENCORE, the goal was to create a mechanism for involving veteran community stakeholders in the process of setting a research agenda. A research agenda is a plan that clearly identifies needs or gaps in a body of work and designs a strategy to address those gaps. This plan identifies priorities in a specific area of inquiry—in ENCORE’s case, veteran community reintegration—to help guide funders’ and researchers’ decisions about the kinds of research that are needed and the methods that could be used to deepen the impact of the research.
The following partial narrative was written by ENCORE’s Principal Investigator (i.e., the team’s lead). It describes her experience growing up in a military family and how working with veterans as a VA researcher helped her better understand her father’s transition experience from a new perspective. Karen’s narrative was included here to illustrate how Karen’s experience as a military family member, a clinician, and a veteran community reintegration researcher inspired and shaped the ENCORE project.
I am a second-generation military brat. My paternal grandfather served as a dentist in the US Army Air Corps. My father was career-military, serving first as an enlisted service-member in the Army, then as an officer when he re-enlisted as a podiatrist where he served until he medically retired at age 48, just two years shy of full retirement. To me, working at the VA is a way to give back in honor of all I had received through my family’s military service. Soon after I began I started working on community reintegration research. This included working with veterans who had their entire worlds and identities upended by leaving everything they knew when they transitioned from the military to civilian life. It was through this work that I made the personal connection with veteran community reintegration and my family. Until then, I always thought of veteran community reintegration issues only as they related to combat deployment and injury.
My father had medically retired at age 48, unable to practice his beloved career any longer. We then moved across the country to be near family and were two hours away from any military base. He was one of many veterans who refused to go to the VA. Without his identity as an Army Officer or a well-respected podiatrist, away from any community or way of life that he recognized, and not knowing how to carve out the next part of his life, his light went out. Veteran community reintegration research, programs, service, and outreach could have changed not only his life but our whole family’s.
This is how I knew that not only did community reintegration issues potentially impact all veterans, regardless of deployment or injury status, but, based on my own clinical experience and training in applied anthropology, that any research had to include stakeholder engagement and be inclusive of multiple perspectives and experiences. This approach is important to help everyone at the table realize that their perspective—driven by personal experience, strategic goals, lightbulb moments—is strongest when shared in this group to develop veteran community reintegration research priorities, agenda, interventions, and programs that are relevant, innovative, and sustainable.
Like Monica, Karen’s narrative situates her work within her autobiographical memory, describing how her experience growing up as a member of a military family shaped the research she does today. Also, like Monica, Karen views her work as a VA researcher as a continuation of her family’s service. Karen’s narrative describes an unfortunate but common scenario: veteran services are available but not accessed by their intended populations. Preventing such scenarios is one of the key benefits of veteran CEnR.
When—as in the case of ENCORE—veteran communities are engaged early in research to identify needs, define issues of importance, and set priorities that matter to them, the findings from these endeavors can be used to design services that appeal to this community (Haynes et al., 2018; Luger et al., 2020). This is particularly true of veteran community reintegration research because the reintegration process is complex. The experience is personal to each veteran, yet it involves many actors including families like Karen’s (DeVoe et al., 2012). Karen’s narrative also describes how working with veterans in her own research expanded her view of veteran community reintegration from a narrow issue-related focus, such as disability or combat, to a broader view of transition challenges faced by veterans across the life course. This serves to highlight another benefit of MSPs: exposure to a diversity of perspectives (MacDonald et al., 2019; Sloan & Oliver, 2013).
The ENCORE team chose to engage veteran community stakeholders in an MSP to meet the project’s goal of improving VA policies, programs, and services that support veteran community reintegration. This is accomplished by (a) mobilizing veteran community reintegration research, and (b) communicating and exchanging information about these research needs. The MSP meets regularly (initially monthly, then quarterly) using virtual conference software due to the COVID-19 pandemic. Standard group facilitation methods are used to support the MSP as they meet objectives and milestones (Veterans Health Administration National Center for Organization Development, 2013).
The MSP was assembled with great intention. Inclusion criteria for VA program officers, community organization representatives, and veteran community reintegration researchers were set to assure that the work of each member (a) aligned with key community reintegration domains (Elnitsky et al., 2017; Resnik et al., 2012), and (b) supported populations that are at greater risk for reintegration challenges or are underrepresented in veteran community reintegration research. Veterans, their families, and caregivers were chosen from among applicants who responded to advertisements. The following partial narrative, written by MSP member and veteran community organization representative Marete Wester, was included here because it illustrated the intention that drove the creation of the MSP. The intent was to ensure that the MSP could, individually and collectively, understand the issue of veteran community reintegration personally, holistically, and as an issue of shared community responsibility.
I have worked in the nonprofit arts sector for more than 30 years. The last 10 have focused on fostering strategic partnerships across the public and private sectors at the national, state, and local levels to increase access to the arts and creative arts therapies for the health and wellbeing of service members, veterans, their families, and caregivers.
It was within this context of personal experience that, when I was invited to join ENCORE’s MSP, my answer was an immediate yes. My focus over the past decade has taught me that real change happens by working collaboratively across sectors, professions and disciplines with support and intention.
America’s longest-running wars have surfaced the realities society as a whole must work together to confront. And while the recent wars have perhaps created a sense of urgency and awareness among a growing segment of the civilian population, the issues veterans are confronting today are not new—they have been with us throughout our history. There are millions of veterans today from both wartime and peacetime generations, who are dealing with unresolved mental health, employment, social support, and health stressors daily as a result of their military experience.
The challenge of increasing access to arts programs benefiting military connected populations has increasingly been taken up by many key stakeholders and providers, including the National Endowments for the Arts and for the Humanities, the US Departments of Defense and Veterans Affairs, along with veteran service organizations (VSOs) and arts partners, such as my own organization, Americans for the Arts. Research into the value and kinds of impacts of these experiences continues to be a top priority among these partners. This effort requires more than any one agency alone can achieve.
Efforts such as ENCORE, with its goal to identify and overcome delays in improving VA policies, programs, and services that support veteran community reintegration are compelling because the MSP structure itself, composed of VA and non-VA operational partners, community reintegration community program leaders and researchers, as well as veterans, their families, and caregivers, is one that I have seen work within my own domain. These efforts are well worth the time as well as sustained investment and continuous input from key stakeholders to ensure their success.
As Marete notes, the past two decades of war have highlighted many of the challenges veterans faced throughout history. However, intentional programs, such as Americans for the Arts, can help veterans who are struggling after serving in the military (J. DeLucia & Kennedy, 2021; J. M. DeLucia, 2016; Levy et al., 2018). Moreover, programs outside the VA are imperative to veteran health, as these programs not only fill the gaps that the VA does not cover, but also reach veterans who are unenrolled or ineligible for benefits (Moriarty et al., 2015; Sayer et al., 2015). As a result, bringing representatives from the VA and the community together is essential because the stakeholders involved can learn from each other. This underscores one of the central characteristics of an MSP: to achieve goals that no one group can achieve independently (MacDonald et al., 2019; Sloan & Oliver, 2013).
Instill[-ing] a confidence that deeper change is possible at the VA.
In year one the MSP: (a) defined their mission, vision, and values; (b) established a framework for understanding veteran community reintegration; and (c) created a research agenda for veteran community reintegration. The agenda setting process included: (a) determining guidelines for inclusive veteran community reintegration research; (b) establishing a shared understanding of the state of veteran community reintegration research, including gaps; and (c) generating and prioritizing veteran community reintegration research topics. In year two the MSP is creating a communication plan to share the research agenda with diverse stakeholder groups.
The MSP’s mission is to maximize veteran and family community reintegration by working collaboratively to share information seamlessly, promote innovative research, and inform equitable veteran policies and programs. Its vision is that every veteran and their family can live and thrive in their desired community. Its values include collaboration, diversity, innovation, integrity, and veteran-centeredness (see Table 1 below).
|Collaboration||We engage stakeholders as partners to make decisions.|
|Diversity||We commit to equitable and inclusive veteran community reintegration research.|
|Innovation||We promote research that offers creative and resourceful solutions.|
|Integrity||We conduct honest, ethical, and transparent research.|
|Veteran-centeredness||We empower and amplify veteran voices.|
As defined by the MSP,
Veteran community reintegration is an individualized process by which a veteran transitions from one functional role/status to another, sometimes resulting in changes to the veteran’s personal identity. This process can be cyclical and extend across the veteran’s lifetime. The process is collective and necessarily includes the veteran’s family, caregivers, and communities of choice. Successful community reintegration is determined by the veteran’s own goals for achieving wellbeing as they transition, can be challenged by barriers that exist within the veteran’s social, cultural, or environmental context, and requires connection to a broad system of resources and supports. (Hahm et al., 2021, p.1).
The MSP’s veteran community reintegration research agenda is designed to be inclusive, innovative, and maximally meaningful to all stakeholder groups. In determining their research priorities, the MSP emphasized topics that would focus on the life-course of the veteran, support advocacy efforts for all veteran populations, including those that may be marginalized, and create pathways for veterans to connect with community reintegration resources. After reviewing gaps in the literature, discussion and group consensus, the MSP identified three priorities to advance VA HSR&D’s veteran community reintegration research:
The following partial narrative was written by MSP member and VA provider, Angela Giles. Her narrative was included here because it illustrates the vested interest that clinical providers have in understanding the complex challenges and diverse experiences veterans face when transitioning from the military to civilian life. Angela’s narrative demonstrates the VA’s aforementioned commitment to veteran-centric services and establishes a natural linkage between the desired outcomes of veteran-centered care and engagement in research, to provide relevant and appropriate clinical care and services.
Joining the MSP has provided me the unique opportunity to have robust discussions related to the specific needs and interventions for sustainable veteran community reintegration, measurement tools to identify risks and quality services, and programs that can improve outcomes for the veteran population. For 14 years I have seen these needs first-hand as member of a primary care mental health integration team who works with veterans enrolling for VA services for the first time. During the initial primary care visit, the veteran may report difficulties transitioning from military to civilian life. Things like social isolation, the impact of physical health on mental health, substance use disorders, and the housing environment are some examples. Connecting veterans to high-quality programs and services is vital to assisting with reintegration into communities. Veterans need resources to improve their quality of life, wellbeing, and overall health. Consider the following example from my career:
After serving in the military, a veteran told me he was experiencing chronic back pain and depression. He felt that the constant pain impacted his ability to work, interact with others and complete physical tasks around his home. We connected him to individual sessions that gave him the opportunity to discuss how the pain impacted his life. We also recommended Cognitive Behavioral Therapy so he could learn nonpharmacological approaches to address his pain. Later, I saw him walking with his cane at a local walking trail. He said, “I pulled out the information you gave me years ago and decided I would try and walk today. I couldn’t walk the whole thing, but it sure feels good to get moving again.”
I was also personally interested in the MSP because it is diverse in expertise, experience, levels of leaderships, military service, and culture. Research should reflect the overall makeup of the veteran population in terms of gender, race and ethnicity, sexual orientation, and religion. Minority representation in research is important because when these groups are underrepresented, the policies, interventions, and treatments that come from the research don’t reflect the diversity of the culture in society. There are a number of benefits of being a part of a diverse team. There have been new perspectives, broader ideas, problem-solving strategies.
Angela’s narrative highlights the fact that veteran reintegration issues often manifest in complex ways across multiple physical, mental and social pathways throughout the life of the veteran (Pedlar et al., 2019). Veteran community reintegration requires a multifaceted approach from clinical, mental health, social, and community partners. A provider like Angela who practices veteran-centered care has an awareness of veterans’ personal community reintegration goals and can provide more personal and individualized therapies and care plans that better meet those overall goals. Engaging such providers in research—along with other members of the veteran community—can strengthen the acceptability of clinical therapies, technologies, and practices. Providers can also champion research findings and hasten their implementation into clinical practice and policy (Miech et al., 2018).
The MSP also developed the following four principles for inclusive veteran community reintegration research to ensure that research is relevant to the veteran community (see Table 2 below). These principles are included in the Veteran Community Reintegration Research Agenda and are recommended to guide funders, researchers, and stakeholders.
|Ensure community reintegration research programs reflect the makeup of the veteran population (e.g., race, culture, language, etc.).||
|Focus community reintegration research programs on the interests of the veteran community, addressing issues that matter to them.||
|Access and represent the views and experiences of the communities in which veterans live and work.||
|Engage veterans and members of the community in meaningful dissemination in accessible formats.||
The following partial narrative from MSP member Kai is included here because it highlights that veteran CEnR can facilitate representation in veteran community reintegration research, especially for populations who have previously been excluded from these discussions. As a member of a minority community and an advocate for inclusive research, Kai explains why participating in the MSP was important to them.
I joined the ENCORE MSP to collaborate with a community of fellow advocates seeking to use research to improve veterans’ lives and contribute to a shift in the process of veteran research. My work has been largely focused on advocacy for minority veterans, as these communities do not receive much attention in veteran research overall, much less as consultants in the design phase of research projects. Researchers who do not consult the communities they are studying are not only missing a critical opportunity to address their most salient challenges, but they are also diverting resources toward issues which may ultimately be negligible in the lives of those communities. Given that research takes nearly two decades to influence health practices, engagement with communities being studied becomes not only more urgent, but ethically imperative.
ENCORE’s MSP presents a model for researchers to substantively engage with their target community, as it draws from the expertise of both members of the veteran community and those who serve veterans. The inclusion of advocates was uniquely important, as it both legitimized our insider knowledge and allowed us to share our knowledge about engaging with veterans. In addition to having the potential to directly inform research design, participant outreach, and survey and interview practice, it also created new ways to think about knowledge translation and application of research findings and recommendations among both researchers and advocates. These conversations also allowed me to more deeply understand and articulate the multiple forms of marginalization faced by minority veteran communities, as the ENCORE team made a concerted effort to fill the gaps in community reintegration research and health practice relating to the unique needs of minority veterans.
Working with other veterans and veteran advocates on the MSP was also rewarding, as our meetings fostered open dialogues between many experts, each with a unique view into the needs of the specific populations we all serve. This led to new approaches in both the ENCORE project and in my own work. Additionally, the immediate feedback between researchers, veterans, and veteran advocates on a variety of topics instilled a confidence that deeper change is possible at the VA, as well as powerfully demonstrating the possibilities of research as a collaborative process and tool to further MSP members’ advocacy work.
As Kai discusses, it is ethically imperative to not only conduct inclusive research, but also to ensure that the findings from the research shape health policies in a timelier manner than they currently do. Here, advocacy is again linked to veteran CEnR. By including advocates in the MSP, conversations were able to include those voices which have often been excluded. As Williams and colleagues (2018) argued, the inclusion of advocates is essential to shaping public health and health policy (Williams et al., 2018). As health policy embraces more holistic approaches, it is all the more important that the representative voices of all veterans are heard, as opposed to just those that have historically been involved in decision making processes. In doing so, veteran health care will become more integrated and inclusive, making it possible for more veterans to get the healthcare that they need (Reddy & Wisneski, 2022).
The MSP’s collaborative findings will be of great interest to those working on transition/reintegration research.
Coauthoring this paper with MSP collaborators was a novel experience for the VA ENCORE research team. They were excited for the opportunity to apply CEnR principles to a traditionally academic dissemination modality. Although the writing prompt and writing partner meetings helped guide the narratives produced by MSP volunteers, the points of view expressed in each narrative were as unique as the writers themselves. Whether by design or by chance, each writer’s narrative evoked benefits and outcomes of CEnR that are described in the literature. Benefits such as increased trust between researchers and participants, outcomes that matter to end users, methodologies that optimize data collection and validity since stakeholders know their worlds and contexts better than investigators, and buy-in that motivates participants to participate in future research endeavors (Ali et al., 2019; Atkins et al., 2016; DeVoe et al., 2012; Dobson et al., 2021; Fielden et al., 2007; Franco et al., 2021; Hyde et al., 2018; Resnik et al., 2012). The writings of MSP members Chris and Kai underscored another important outcome of CEnR: the moral obligation to democratize research. Engaging stakeholders promotes transparency in the research process and creates a system of accountability that ensures those who are researched shape the research (Esmail et al., 2015).
MSP narratives also strongly emphasized that veteran CEnR practices and designs can facilitate what True et al. (2021) termed the more “humanistic” outcomes of this approach, outcomes like trust, connectedness, and service to and advocacy for the veteran community. Advocacy in particular has been described in the literature as an unintended and less measurable outcome of veteran CEnR that has immense potential to build trust between the veteran community, the scientific community, and the VA—a primary goal of CEnR—and motivate further participation in research. (Dobson et al., 2021; True et al., 2021) In fact, a 2018 article by Littman et. al., found that post-9/11 veterans were motivated to participate in research, in part, when they believed the research would help other veterans (i.e., service and advocacy) and when they believed the research topic was relevant to their lives.
The benefits described above support the uptake of veteran CEnR in all areas of veteran studies. However, several researchers have argued that more should be done to advance the science of CEnR by increasing evaluation of this approach using valid measurement tools (Esmail et al., 2015; Goodman & Sanders Thompson, 2017; Hamilton & True, 2016; Luger et al., 2020; True et al., 2021). Esmail et al. (2015) pointed out that it is especially important for researchers to demonstrate the cost-effectiveness of CEnR because this approach is time consuming and requires extended commitment on the part of researchers and participants. In their 2020 mapping review of community engaged research contexts, processes, and outcomes, Luger et al. (2020) concluded that the recent proliferation of CEnR approaches in the scientific literature indicates that it “is more important than ever for those conducting CEnR to…demonstrate impacts of CEnR over time, and for the field as a whole to make a case for the value of CEnR” (p. 509). They described a current lack of consensus in the literature about the definitions, domains, measures, and goals of CEnR.
Thus veterans studies researchers who choose to employ veteran CEnR approaches should include quantitative and qualitative measures of engagement that beget richer understandings of the characteristics and constructs of “good” CEnR in addition to the specific aims of their research. In applying veteran CEnR to the authorship of this article with methodological transparency, the authors attempted to respond to Luger et al.’s (2020) call for qualitative insights (i.e., hearing from stakeholders in their own words) that “can lead to better conceptualization and operationalization of engagement” (p. 508).
In establishing the ENCORE MSP to develop a VA veteran community reintegration research agenda, the ENCORE team found that a diversity of experience yielded a relevant research agenda that might deepen researchers’ understandings of the veteran community’s priorities for research, activate researchers to address these priorities, and mobilize research and dissemination efforts to improve veteran community reintegration outcomes. Similarly, veteran CEnR resulted in MSP products that have the potential to advance the field of veteran community reintegration research. Products like the MSP’s stakeholder-driven definition of veteran community reintegration and principles for inclusive community reintegration research can support future research efforts. The work of ENCORE and the MSP is ongoing. Next steps include disseminating the veteran community reintegration research agenda to VA and non-VA veteran community reintegration researchers and providing technical assistance and consultation services to veteran community reintegration researchers who want to include veteran CEnR methods in their work.
Not only has the MSP worked with the ENCORE research team to develop and prioritize a relevant agenda, but they have also developed a community of understanding and respect that is working to ensure this agenda is implemented into veteran community reintegration research studies and evaluations. In this spirit, the article closes with the following narrative, written by MSP member Jim Thompson, that illustrates the mutual benefit experienced by members of the MSP and the far-reaching influence of such partnerships when guided by the principles of CEnR.
I am grateful to the US VA ENCORE team for inviting me to participate in their MSP. I was asked to bring a Canadian perspective to the MSP from my role as a physician-researcher and former Reservist with an interest in the well-being of military members and veterans (former members) across their life courses, particularly as they transition to life after service (Castro & Dursun, 2019). Listening to the diverse MSP viewpoints has broadened my understanding of the complex transition experiences of members and their families, and the research that needs to be done to inform effective policies and services. The MSP’s collaborative findings will be of great interest to those working on transition/reintegration research priority-setting in Canada and other nations.
This material is based upon work supported (or supported in part) by the US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development Service. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the US Government.
This project was determined to be Quality Improvement (QI) evaluation by a local VA Research and Development committee.
We would like to acknowledge and thank every MSP member who works so diligently to improve veteran community reintegration, especially James Thompson, MD, CCFP (EM), FCFP who contributed to this article, but did not wish to be authored. The authors also wish to thank the following colleagues who generously volunteered their time to review different iterations of this article and provide feedback: Wendy Hathaway, Chaady “Chad” Radwan, Blake Barrett, and Remington Bronson. Finally, we thank Alexis Hart for her guidance in helping improve this paper.
This material is based upon work supported by the US Deptartment of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development (IVI 19–487).
The authors have no competing interests to declare.
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