To our knowledge, this was the first study to examine barrier reduction components present in programs that are designed to assist post-9/11 veterans as they transition from military to civilian life. Perhaps most striking was the finding that, of the vast majority of the programs that were coded, a low proportion offered any barrier reduction components. Research in program implementation science has consistently demonstrated that barrier reduction is critical to bolster program participation and sustainability (25, 26). Thus, while the results of this study indicate that a significant proportion of new post-9/11 veterans use VA programs, there is a need for non-VA sponsored programs to consider implementing barrier reduction components.
The study also revealed that a low proportion of new post-9/11 veterans report using and benefiting from barrier reduction components. The most commonly mentioned barrier reduction component that was reported as being used and helping veterans achieve their goals (i.e., assistance for obtaining VA benefits) was mentioned by less than 25% of the sample. Seven components coded from websites were not mentioned by any veterans, and a sizeable number of barrier reduction components were only mentioned by less than 10% of them. The most parsimonious explanation for this finding is that recently separated post-9/11 veterans do not need to use programs or take advantage of barrier reduction components. A number of studies have shown that most veterans make a healthy transition from military life to civilian life (2). Perhaps, the need for programs and the need for barrier reduction components increase over time. Future studies should examine this question. Nonetheless, a sizeable number of recently separated post-9/11 veterans do not access programs often because they do not understand their eligibility, do not know what programs they qualify for, cannot find an appropriate program, or encounter other challenges to help seeking (17). Clearly a proportion of veterans could benefit from barrier reduction components, particularly related to accessing programs.
Given limited resources, efforts should be made by programs to include barrier reduction components. For new post-9/11 veterans, the following supports are the most important barrier reduction components they use in helping them reach their goals: assistance for obtaining VA benefits, increasing motivation to change, provision of non-VA insurance or free medical care, and non-VA tuition discounts/ scholarships. Unfortunately, very few programs offer these barrier reduction components. For example, while only 6.3% of programs offered an increased motivation to change component, 17.5% of veterans reported using and benefiting from this type of component. Because veterans value the increased motivation to change component, programs should consider adopting this component (e.g., using motivational interviewing). Perhaps more importantly, on the whole, a low proportion of veterans report using and benefiting from barrier reduction components. Thus, not only are barrier reduction components not offered enough, but the quality and/or impact of these components may be suspect. Indeed, research on the impact of barrier reduction components is lacking, and future research should address this gap.
The results of this study also demonstrate that there is often a misalignment among the barrier reduction components coded as being present in programs; the use and benefit of barrier reduction components; and, among programs offering these components, the proportion of veterans who report using them. For example, while increased motivation to change was coded in only 6.3% of programs, 17.5% of veterans reported using and benefiting from this component. In addition, among programs offering this component, 29.3% of veterans reported using it. While there is no research related to barrier reduction misalignment, it seems reasonable to think that lack of alignment is a problem. Alignment among what components are offered, used, and are helpful would be ideal in terms of meeting veteran needs. It is possible that alignment improves over time; however, this assertion has yet to be examined.
For new post-9/11veterans, tangible support components were the most widely used, and this was particularly true for VA programs. Three-quarters of new veterans reported using at least one VA program. VA benefits are a unique tangible support component because they are offered at no cost and directly enable a person to obtain a desired outcome (i.e., higher education or home ownership). VA-sponsored education was used by 43% of the sample. This assistance enables veterans or their family members to achieve a higher level of education. Education is, of course, positively associated with a host of health and well-being outcomes (e.g., higher paying jobs, lower morbidity). The VA home loan benefit was used by 32% of veterans. Veterans whose military occupation was combat arms and combat support were more likely to utilize educational benefits because their military occupations may not translate directly to civilian occupations; thus, additional training could be needed to find employment within the civilian population.
Three additional commonly reported tangible support barrier reduction components were directly related to meeting a veteran’s economic needs (i.e., cash, clothing and consumer goods, food, and discounted pricing on goods and services). A subset of post-9/11 veterans struggle financially, and this is particularly true for veterans who have health problems (41), live in poverty (42), and are female (43). More community-based organizations should consider focusing on providing for the basic needs of this subset of veterans and their families.
In comparison, very few veterans (16%) utilized the access barrier reduction components for non-VA benefits (e.g., Tricare, Medicare, Army Wounded Warrior Program). One potential reason may be that veterans may not be eligible for all barrier reduction components available within a program, or another cause may be veterans are unaware of the resources available to them when using a program. For example, income guidelines or minimum credit scores may need to be met before a veteran can access certain benefits.
The barrier reduction component of access assistance was also found to be a helpful tool that veterans used. For instance, approximately 33% of veterans report utilizing at least one VA healthcare service (i.e., hospital, clinic, or Vet Center). Moreover, as consistent with previous research (32), veterans with a medical discharge were 24% more likely to use VA healthcare services. In addition, veterans with ongoing physical health conditions were two times more likely to utilize VA healthcare, and those with mental health problems were 58% more likely to use VA healthcare compared to those without physical/ mental health conditions. Access to VA benefits is a primary concern for veterans as they transition to civilian life (17). Further research should explore which specific VA benefits are the most challenging to navigate, and strategies to help veterans overcome these challenges should be investigated.
The majority of programs were found to make access easier by making some of their materials available online (97% of programs). For example, the VA is widening its access to veterans by providing more administrative support and clinical care via the web. However, navigating the internet to find the specific program may still be troublesome for some veterans. In this ever advancing technological world, web access will play an increasingly important role in the lives of veterans; however, rural dwelling and older veterans often have poor or no access to the internet (44). Thus, extending the reach of internet access to rural areas could close the gap in web access.
Transportation appears to be a key access assistance component particularly for veterans with serious injuries or disabilities that prevent them from getting around by themselves or for those who do not have the financial means to purchase and maintain their own transportation (45). However, while 20% of veterans nominated programs that offer transportation, only 2.7% reported using and benefiting from the component. Transportation for subsets of veterans may still be important, and these subsets should be identified. In this study, veterans who screened positive for PTSD symptoms were two times more likely to utilize programs with a transportation component. On the other hand, veterans with physical health conditions were not significantly more likely to utilize programs that provide transportation. As a result, to the extent possible, program developers should think strategically about which veterans will value and benefit from a transportation component and which veterans will be less likely to use this option. In so doing, developers will be able to incorporate the provision of transportation as part of their program’s portfolio of support in a manner that matches veteran needs.
Access to child care can be a barrier reduction component as it could give Service members free time to utilize programs or pursue employment or educational opportunities (46). However, child care was rarely mentioned by veterans as a barrier reduction component that programs offered. Prior research has shown that veterans report having limited access to child care services in the community (47). Moreover, male and female veterans report that the VA should offer child care services and, if these services were offered, they would use them (47). Several studies with civilian families demonstrate that the provisions of child care and meals are inducements to program participation, particularly for families who experience financial and other hardships (48–50). The provisions of child care and meals to enhance program participation, while primarily used in prevention research studies in university-community based partnerships, are barrier reduction components that may be transportable to other community-based organizations that offer programs to veterans and their families.
The barrier reduction components related to intra-individual change (i.e., focus on increasing motivation to change and stigma reduction) were present in a low proportion of coded programs. However, these components were used and viewed as helpful by 17.5% of veterans. Among those programs that offered this component, 29.3% of veterans reported using it. Military and veteran cultures foster norms that stigmatize help seeking, particularly for mental health problems (51). Active duty military and veterans also express a significant degree of distrust of institutions designed to support them (19). Senior enlisted and officers were more likely to utilize programs with a stigma reduction component compared to junior enlisted (E1 to E4). Veterans with a mental health condition were two times more likely to utilize programs with a stigma reduction component. Thus, the results of this study suggest that the intra-individual change components should be a focus of programming efforts. For example, approaches designed to reorient norms of military and veteran norms to be more open to help seeking and more accepting of people’s health challenges (10). Several attempts at stigma reduction approaches have been developed for the military and veteran contexts (35, 36, 52), however, they have yet to be evaluated for effectiveness. Veteran serving organizations should investigate the feasibility of adopting these approaches.
As with any study, there were some limitations with the current investigation. First, while the sample is large and represents the population of recently transitioning post-911 veterans, the sample is not designed to represent the veteran population overall, which includes many veterans from earlier military conflicts. Second, veterans were likely to use more programs than they described in detail because the survey limited in-depth self-report information to two programs.
Third, there may be differences between what the coding rules counted as components to a program and how a veteran perceives that program’s components as helpful in achieving their goals. Future qualitative work is recommended to elucidate veteran perceptions of specific program components. Fourth, this study examined the first three months after separation from the military. Additional transition and reintegration program use continues to occur. Fifth, the analysis of web-based coding may be biased because there may be differences between what was offered to veterans and the veterans’ own perception of what was offered. Nonetheless, what seems most important is whether or not veterans perceived the program components as helpful or not.