Seven focus groups with 38 participants (12 veterans and 26 stakeholders) were conducted between August and October 2019. Focus groups lasted approximately 60 minutes. Three veteran focus groups were held and ranged from 2-5 participants. Four stakeholder focus groups were held and ranged from 4-10 participants. Three participants (two veterans and one stakeholder) were unable to make a focus group and, instead, engaged in a one-on-one interview. All interviews lasted approximately 30 minutes. This provided a total of 41 participants. Participants’ age ranged from 24-65 years old and the average age of all participants was 39.6 (SD = 10.1). Additional participant demographics are provided in Table 1.
Veteran participants. The average age of veteran participants was 38.5 (SD = 11.2). Most participants had served in the Army (71.4%) and had seen combat (78.6%). Most veterans indicated they were employed (64.3%), several were retired (28.6%), and a few were unable to work due to disability (21.4%). All veteran participants were receiving VA care at the time of study participation.
Stakeholder participants. The average age of stakeholder participants was 40.2 (SD = 9.7). Most stakeholder participants were YMCA employees (51.9%). Five stakeholder participants (18.5%) indicated being military veterans.
Analysis revealed three main themes: 1) enhancing program recruitment and retention, 2) the perceived ability of a health promotion program to provide more holistic, veteran-centered care, and 3) using health promotion programs to help veterans establish structure in their daily lives. These themes reflect the perspectives of both veterans and stakeholders. Significantly differing perspectives between veterans and stakeholders are highlighted within the theme discussions below. This section, in alignment with rigorous thematic analysis, provides detailed descriptions and quotes to aid the understanding of how the themes emerged.22 The participant ID is provided after the identifier (i.e., veteran, VA stakeholder, YMCA stakeholder) in parenthesis. Table 2 provides an overview of the three themes and their alignment with the constructs of the two theories (IPT and SDT) that informed the development of the RECLAIM program.
- Enhancing program recruitment and retention. Focus group participants frequently discussed how to get veterans interested in a health promotion program, what would be necessary for buy-in, and how to keep veterans engaged in program activities, even after the program concludes.
Being clear on purpose and process – Participants discussed how veterans would be reluctant to participate if the program’s purpose and activities were vague. It was frequently suggested that peer-to-peer outreach (i.e., former program participants should be invited to speak about their experience) should be used to promote the program and create immediate buy-in.
“If you could have a [veteran] that [others] respected and could sit down with everybody, all of the guys that are getting out or whatever and you talk about these things and be like look, y’all are about to get out. The transition is difficult. Like if you have a respected [veteran] talk about this…the [veterans] would listen.” – Veteran (V12)
Participants with previous experience practicing mindfulness techniques suggested being clear on the level of difficulty involved in learning the proposed activities.
“These things are not very easy either, right? They are something that require discipline and daily practice. It took me some time to accept that in order to live a normal life again or anything resembling that, that it was going to take effort, constant effort every single day to get from where I was to where I wanted to be.” – Veteran (V2)
“I know how difficult it is to immerse yourself in [mindfulness] work and how brutal, and it requires a lot of like self-accountability and finding the right community support. I love this stuff, but I love being honest about the work that goes into this.” – YMCA stakeholder (S20)
Veteran participants also felt that some of the proposed terminology, such as ‘lifestyle program,’ was “invasive” and “vague” and the lack of clarity would not appeal to a broad veteran audience and could leave veterans wondering “what [they] would share with you.”
“I think that [lifestyle] is kind of a scary word. Because it’s kind of vague. Do you know what I mean? Like it’s a little vague. It might mean different things.” – Veteran (V7)
Use of the term ‘lifestyle’ also made veteran participants question, “why isn’t my lifestyle right now [legitimate]?” or state that “there is nothing wrong with my lifestyle.”
Creating a sense of familiarity – Participants repeatedly suggested that RECLAIM promoters needed to find ways to make the program stand out considering veterans receive a lot of information when they exit the military. Veterans suggested “piggybacking” onto existing military or VA programs to “prime” service members for participation in RECLAIM. Participants also suggested reaching out to individuals before they exit the military to establish a sense of familiarity with RECLAIM prior to transitioning back into civilian life.
“…before people get out of [the military] introducing them to some of these things and programs that are paired up. [Letting them know that] the VA has something that’s similar so that when they get out, it looks and feels like home to them. Because the military was home.” – Veteran (V13)
Participants were also considerate of the fact that many veterans may not be in the frame of mind to consider this type of program upon exit from the service and “may reject it immediately” (Veteran, V3). Even with these challenges, most participants strongly recommended recruiting veterans in the early stage of their career transition.
“Transitioning out of the military, like this would have been perfect. Because, even us younger folks, like, I’m out and I’ve never done anything else. I don’t know how to be an adult.” – Veteran (V8)
“They send out a bunch of stuff, but it’s never anything that pertains to anybody especially like when you first get out of the military. So getting [RECLAIM] to those [veterans] is probably one of the bigger things.” – Veteran (V2)
However, some veterans talked about still needing this type of program even though they had transitioned out several years ago.
“I wish I would’ve had an opportunity like this when I came back from Afghanistan. I think it would’ve made a huge difference for me in my reintegration process. You know, I’ve been home for 7 years and it still feels like yesterday to me. I mean it literally feels like yesterday.” – Veteran (V1)
In addition to providing clarity, terminology was discussed by participants to create a sense of familiarity regarding RECLAIM and its concepts. Participants repeatedly suggested use of the term “resilience” because it is frequently used in the military.
“We always talked about it in the military, being able to build a resilient warrior, right? … Most people that have been around the military would be like, okay, I’m identifying and understanding that context.” – YMCA stakeholder/veteran (S2)
Participants encouraged the inclusion of technology, such as apps or podcasts, which would be familiar to younger “tech savvy” (Veteran, V12) veterans, enhance RECLAIM’s appeal, and increase the likelihood of recruitment and retention of these veterans. This would also allow veterans to access program-related independently, which would support long-term engagement. Apps where veterans could check in were frequently suggested for establishing a sense of accountability and improve program retention.
- The perceived ability of a health promotion program to provide more holistic, veteran-centered care. Participants expressed how the RECLAIM program centered around wellness and how it might encourage veterans to pursue healthcare outside of illness. One veteran participant (V2) described RECLAIM as “more like wellness than health care” because it moves beyond the typical medical model (i.e., specific disease or symptoms) and considered the whole person.
“So having a program like this kind of gets past that first layer of oh, we’re just going to treat your symptom. [This program] is thinking past that. You’re not just treating a symptom. – Veteran (V11)
“If your body is not doing well, then your mind doesn’t do well. And a lot of doctors, they’ll just throw some meds at mental health to try to make you feel better and they don’t take into consideration the exercise, the eating, the environment that you’re in, or the social aspects.” – Veteran (V14)
Proactive care – Several stakeholder participants discussed how RECLAIM was “preemptive” (VA clinician, also a veteran; S1) and “[liking] the idea of being proactive instead of reactive” (YMCA stakeholder). A VA clinician (S5) also expressed how programs like RECLAIM are “a good way to start that paradigm shift for more preventative help.”
“The VA’s system is kind of set to react. And this is the first time we are shifting our model to prevention, which I think it’s a good time to do it with the [younger veterans]. So I think [RECLAIM] is a neat way to get it started.” – VA clinician (S10)
Several participants suggested that veterans may engage with RECLAIM and acquire information that encourages them to seek additional care and may positively impact their health long-term. As such, the RECLAIM program was considered a valuable opportunity to help connect veterans to their VA benefits.
“I think you would have to say it’s something connected with the VA, because I don’t think a lot of people, a lot of soldiers, don’t know how to get into the VA. …But I think saying something like this is VA, like associated with the hospital would be big because then veterans are going [to understand] like this is the information you need for whatever [benefits]. – Veteran (V1)
Some participants expressed how the mindfulness component of the RECLAIM program could help veterans 1) be more attuned to what was going on with their health, 2) understand why they feel the way they do, and 3) recognize that “[they’re] in control of all of these things” (Veteran, V13).
“You know mindfulness is huge for everybody. But being self-aware is, sometimes we don’t realize our problems until we see ourselves more clearly. And I think that that’s a really great benefit to the program if they can be more mindful of – oh I didn’t realize I was feeling this way, or I didn’t realize how my behaviors or habits were shaping my mind state or you know my health. – VA clinician (S8)
“Like it’s just the world that we live in, how busy we are, and how much we put on our plates that we…. It’s very easy to be unmindful, which makes us feel more disconnected.” – Veteran (V9)
Community-based setting –Participants indicated that the space for conducting the program “feels less clinical” (Veteran, V2) than a hospital setting and would provide a “quiet space” (Veteran, V3) for veterans to focus on things like meditation and breathing.
“So I think if we you know do more community partners and take things out of the stigma of the VA … I think getting out into the clinic is a wonderful way to think outside the box.” – VA clinician (S10)
“I mean I love my country but flags and military logos and the president and all that I mean it’s not going to feel like a relaxing environment to me, you know? …if you really want me to relax, that’s probably not the best way.” – Veteran (V2)
Some veteran participants also discussed how the environment of a VA medical center may cause unpleasant feelings and that for some veterans “it’s very stressful to go to the VA” and “it is depressing [and] very sad” (Veteran, V1). Another veteran (V4) didn’t think the setting would make a drastic difference for most veterans and some veterans may positively view the VA environment “because everybody’s there.”
- Using health promotion programs to help veterans establish structure in their daily lives. Veterans discussed how they had grown accustomed to the structure of the military and “how everything was provided” and that “when [veterans] get out, [they] go through a loss period and [they’re] trying to find a connection.”
“I’m out and I’ve never done anything else. I don’t know how to be an adult. Because the military told me what to wear, when to be there. They provided me a nice check…gave me clothes, food, and everything. So for me to get out, I have to do it all by myself, everything.” – Veteran (V8)
“I know that a lot of military members struggle to assimilate to civilian life because they have such a structured lifestyle while they’re in the military that when they’re out on their own, they have nobody to help hold them accountable besides themselves.” – YMCA stakeholder (S24)
Participants agreed that providing structure would be especially beneficial for younger veterans who entered the service prior to acquiring a sense of independence and “don’t have that experience and don’t know the questions to ask” (VA clinician, S13) when they get out of the military.
“[The military] is a high stress job. But then even when you get out it’s different because now, you’re [experiencing] a very different stress. The stress they’re used to is military stress. That is something you can handle because you’re going to do it every day.” – Veteran (V10)
Establishing a mission/purpose – Participants expressed that it was important for veterans to have a sense of purpose and passion because, if they “don’t have purpose in life, [they’re] not going to be driven to take care of yourself because there’s nothing that you’re striving for” (VA clinician, S14).
“It’s easy for people to push past some of these barriers and start reclaiming their life if they have that mission or purpose.” – YMCA Stakeholder (S26)
Veterans discussed how “you know what’s expected of you” (Veteran, V1) in the service and this creates a “very strong purpose, drive, [and] mission” (Veteran, V12). However, this purpose, drive, and mission becomes lost in translation when veterans exit the service. Participants expressed how RECLAIM could help veterans establish a “new normal” (VA clinician, S6) within the civilian world, while also acquiring additional skills and resources.
“If you’re out of the military and that was your mission, like taking some time over those 8 weeks to maybe develop what that is and then reinforce it with health care skills that help them to build off of it.” – VA clinician (S4)
“If you don’t have a sense of purpose, like you’re starting to fall into some [stuff], you know, this [program] is a tool that you can use if you start feeling that you’re falling by the wayside.” – Veteran (V14)
Building a support system – Participants discussed how RECLAIM could help veterans rebuild a support system. Social support was considered an important aspect of the program because there is a tendency to “isolate yourself when you get out,” which “creates so many downstream effects” (VA clinician, also a veteran; S1).
“You had that brother and sisterhood [in the service] and I think that [RECLAIM] would be a great thing to have, especially to include into tools for new veterans.” – Veteran (V13)
One veteran (V11) indicated he “didn’t think there was much of a veteran community around.” Participants expressed that the RECLAIM program could help strengthen the veteran community by actively connecting veterans and their families with community resources. Some stakeholders echoed these considerations about helping veterans “understanding the resources that are available to them” (VA clinician, S14). Stakeholders also viewed RECLAIM and its positioning within a community-based organization as an “opportunity to create partnerships” (VA clinician, S10) in the community.
Inclusion of family, especially spouses or significant others, was frequently discussed and suggested for consideration within RECLAIM to help veterans re-establish their support system. However, there was some inconsistency about whether inclusion of family was always a positive and necessary aspect of the program; one veteran (V2) shared that the program could help “connect [veterans] with [family],” while others thought some veterans may “[not] want [family] knowing what [they’re] struggling with” (YMCA stakeholder, also a veteran; S25).
Theoretical Analysis of Emergent Themes
As presented earlier, the Interpersonal Psychological Theory of Suicide (IPT)5 and the Self-Determination Theory (SDT)14,15 guided the development of the RECLAIM program. The IPT is comprised of two constructs: thwarted belongingness and perceived burdensomeness. The SDT focuses three universal psychological needs: relatedness, competence, and autonomy. The section below discusses how the study’s emergent themes align with the constructs from both the IPT and the SDT. This alignment is also presented in Table 2.
Theme 1: Participants frequently discussed the importance of using familiar language when promoting RECLAIM and presenting program content. Additionally, peer-to-peer outreach (another way to create familiarity) was often suggested. These suggestions are consistent with the theoretical constructs of belonging (IPT) and relatedness (SDT); program materials and content familiar to veterans can provide them with the sense of being connected to the program and its content which, as participants indicated, can increase the likelihood of buy-in and continued engagement.
Theme 2: Participants were drawn to the idea that RECLAIM is proactive and focuses on aspects of the whole person to improve well-being. Some participants also expressed how the mindfulness component of RECLAIM will help veterans be more attuned to and understanding of their health needs and recognize that they are in control. These aspects support the needs of autonomy (SDT) and competence (SDT). The proposed mindfulness activities also aim to improve veterans’ resiliency and coping skills, allowing them to independently address difficult situations or emotions, and prevent the perception that they are a burden on others (IPT). Finally, some participants discussed the benefits of the community-based setting, which can improve veterans’ sense of belonging (IPT) and relatedness (SDT) by connecting them with other veterans in their community.
Theme 3: When veterans transition out of the military, the structure (e.g., financial support, day-to-day schedules) they had become accustomed to is not readily apparent when they leave the service. Therefore, participants perceived RECLAIM as an opportunity to assist veterans’ efforts to replicate the structure of the military into their civilian lives. Providing veterans with structure addresses all five theoretical constructs of both the IPT and the SDT. First, by establishing a new purpose or mission, and related goals, veterans will be able to feel more autonomous (SDT) and competent (SDT) and, therefore, can perceive themselves as less burdensome (IPT) to others. In addition, RECLAIM can facilitate veterans’ sense of belonging (IPT) and relatedness (SDT) by connecting them with other veterans who will be able to identify with their experiences, concerns, struggles, etc. The inclusion of family members, as suggested by some participants, can also increase veterans’ sense of belonging.