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 the vast majority of programs did not offer any barrier reduction components. This is a problem from practical, theoretical, and policy perspectives. Practically, many post-9/11 veterans report barriers to programs that they need (3,17–19). From a theoretical perspective, research in program implementation science has consistently demonstrated that barrier reduction is critical to bolster program participation and sustainability (25, 26). To be most effective, programs should consider using best practices that have been documented in the field of implementation science. The VA has made advances in using implantation science insights by introducing transportation assistance programs and providing satellite clinics in rural areas, and offering telehealth options. The present study suggests that non-VA programs should invest in barrier reduction strategies as well.
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 both used and helpful (i.e., assistance with 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).
From a policy perspective, VA and non-VA program providers should consider enhancing veteran awareness of their programs, providing clear explanations as to eligibility requirements, offering strategic referrals to programs for which veterans are eligible, and prioritizing barrier reduction strategies in their strategic plans. Given limited resources, efforts should be made by programs to include barrier reduction components. For new post-9/11 veterans, the current study suggested that providing assistance with obtaining VA benefits, increasing motivation to change, provision of non-VA insurance or free medical care, and non-VA tuition discounts/ scholarships are the most important barrier reduction components in helping them reach their goals. Unfortunately, very few programs offer these 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). Just as importantly, 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. Research in this area would provide needed information for developing policies to assist veterans make healthy transitions to civilian life.
The results of this study also demonstrate that there is often a misalignment among the barrier reduction components offered by programs and the components that veterans reported as being most helpful. 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. From a practical and policy perspective, 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 (42), live in poverty (43), and are female (44). 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. It is also possible that 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. Implementation science theory and research supports the idea of making access to information and resources more widely available. 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 (45). Thus, policies that extend 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 (46). 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, future research should attempt to understand which veterans will value and benefit from a transportation component. In so doing, program 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 provides service members free time to utilize programs or pursue employment or educational opportunities (47). 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 (48). Moreover, male and female veterans report that the VA should offer child care services and, if these services were offered, they would use them (48). 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 (49–51). 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 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 (52). 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. Greater focus on intra-individual change components makes sense. For example, approaches designed to reorient help-seeking norms of military and veterans to be more open to help seeking and more accepting of people’s health challenges have shown promise (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. The most significant limitation of the study is that the sample was not drawn at random. As a result, the degree to which the findings were biased is not known. Also, participation in the study was voluntary and it is likely that respondents who participated felt strongly about the topic in question and may favor certain responses (54). While the cell weighting used in this study statistically adjusted the sample to better reflect the three characteristics that were known of the population (i.e., gender, paygrade, branch), it does not yield the strength of inference that can be drawn from random sampling. Nevertheless, the opportunity to participate was offered to the population of recently separated post 9-11 veterans during the period of June-September 2016. Moreover, a variety of methods to recruit veterans were used (e.g., phone, paper version, online survey). Thus, every veteran had an equal probability of being invited to participate. Details on the sampling methodology have been previously reported (see Vogt, et al., 2018) and interested readers may consider reading this manuscript. Future studies should consider drawing additional samples of new post-9/11 veterans to compare them to the results of this study. A nationally representative sample of new post-9/11 veterans would yield unbiased estimates of their perceptions of barrier reduction techniques. 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, the analysis of web-based coding may be biased because it is likely that there were at least some 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. 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. Subsequent analyses from TVMI will examine how the perceptions of barrier reduction strategies change over time.