‘It Makes You Sit Back and Think Where You Wanna Go’: Veteran experiences in virtual whole health peer‐led groups

Abstract Background The Veterans Health Administration (VHA) is building a Whole Health system of care that aspires to empower and equip each Veteran to pursue a personally meaningful vision of health and well‐being. As part of this effort, VHA has developed Taking Charge of My Life and Health (TCMLH), a peer‐led, group‐based programme that seeks to support Veterans in setting and pursuing health and well‐being goals. Prior research showed TCMLH groups to positively impact Veteran outcomes; yet, little is known about Veterans' own experiences and perspectives. Methods We completed semi‐structured telephone interviews with 15 Veterans across 8 sites who had participated in TCMLH groups offered by the VHA in the virtual format between Summer 2020 and Fall 2021. Inductive thematic analysis was applied to interview transcripts to generate themes. Findings We identified five themes regarding Veterans' experiences with TCMLH: (1) navigating the virtual format; (2) internalizing the value of health engagement; (3) making healthy lifestyle changes; (4) forging social connections; and (5) taking on a more active role in healthcare. Conclusion Veterans perceived virtual TCMLH groups as meaningful and beneficial, yet also highlighted several challenges. Their perspectives speak to the need to supplement time‐limited programmes like TCMLH with ongoing, community‐based support. Virtual group‐based well‐being programmes are a promising innovation. Other healthcare systems may draw on VHA's experience while tailoring format and content to the needs of their patient populations. Patient or Public Contribution Veterans were involved as evaluation participants. A Veteran consultant, who is a coauthor on this paper, was engaged through the conceptualization of the evaluation, development of data collection materials (interview guide) and writing.


| INTRODUCTION
The Veterans Health Administration (VHA), the largest integrated healthcare system in the United States and key component of the Department of Veterans Affairs (VAs), is in the process of transforming into a Whole Health system of care, which emphasizes promoting the personal health and well-being of each Veteran rather than treating discrete diseases. 1,2 This unprecedented transformation was motivated by recognition from organizational leadership that the older-disease-oriented, reactive and impersonal-model of care has been an exceedingly poor fit for the needs of Veterans, who frequently manage one or more complex chronic conditions while also struggling with service-related injuries and the challenges of readjusting to civilian life. 3,4 While VHA's Whole Health transformation is still unfolding, recent studies have demonstrated that Veteran use of Whole Health services is associated with greater engagement in their healthcare and improved self-management, perceptions of care, life meaning and purpose and perceived stress. 5,6 As other healthcare organizations in the United States struggle with managing burdensome costs and optimizing patient experiences and outcomes, VHA's Whole Health transformation has attracted growing attention from other healthcare organizations that are looking to transform their own structures and processes and implement a patient-centred, proactive approach to care. 7,8 Adopting the Whole Health model, however, may be challenging for front-line clinicians for a variety of individual-and system-level factors. 5,9,10  the key elements remain the same. First, Veterans reflect on their core motivation for becoming more engaged in their health ('what really matters') and assess their current experience across eight dimensions of well-being (e.g., 'moving the body', 'food and drink', 'recharge'), presented as the Circle of Health ( Figure 1). Throughout the rest of the course, participants explore approaches to enhancing their well-being across these different dimensions, set SMART (specific, measurable, action-oriented, realistic and timed) goals 11 and draw on the group for support and accountability. Ideally, by the end of TCMLH participation, Veterans will have developed self-care skills, acquired knowledge about well-being practices that they may want to try (e.g., complementary and integrative health approaches) and gained confidence to take on a more active role in interactions with their healthcare team.
Prior work indicates that TCMLH participation may positively impact Veteran outcomes, including quality of life, sense of meaning in life, mental health and stress, as well as engagement in healthcare and progress towards achieving personal health goals. 12

| Participant recruitment
We invited Veterans (n = 43) who (1) had taken part in TCMLH and (2) had previously participated in a survey about their experiences in TCMLH, to participate in an interview. We completed interviews with 15 Veterans across 8 VHA sites across the United States (see Table 1).

| Data collection
We conducted semi-structured telephone interviews between May and July 2021. Both interviewers (E. A. and K. D.) had expertise in qualitative methods. Interviewers followed an interview guide that was developed with input from the full team, including a Veteran consultant (R. P. K.), and included questions about Veterans' experiences with and perspectives about TCMLH (see the Supporting Information Appendix). All interviews were audio-recorded and transcribed verbatim.

| Data analysis
Our analysis was guided by a thematic analysis approach, a widespread, flexible method for generating a rich description of patterns in a data set without following an a priori theoretical framework. 15,16 We used a combination of deductive and inductive coding. Drawing on a codebook that captured the main domains of the interview guide (e.g., 'curriculum', 'social dynamics', 'perceived outcomes'), coders (E. A., K. D. and Z. R.) coded the same set of three transcripts independently. After meeting to resolve discrepancies in code application and introduce additional codes that reflected emerging concepts (e.g., 'taking responsibility'), coders worked on the remaining transcripts independently. After coding was completed, the team worked to identify and describe overarching patterns and variations across the data set. NVivo qualitative data analysis software (version 12) was used to facilitate coding and analysis. 17

| FINDINGS
We identified five main themes in Veterans' accounts of TCMLH:  Several Veterans also reported staying in touch with other TCMLH participants, and one in particular described a close-knit group that formed after TCMLH was over: …I go to the Y with a few friends that was in the group… and now I feel… comfortable with all the other veterans and <this> makes me feel good that I know I'm helping them out and they're helping me out too.

Participant_01_Site_01
More frequently, interviewees talked about TCMLH as an impetus to spending more time with family, re-engage with old acquaintances or taking on a more active role in their communities. Our key finding was that Veterans who participated in TCMLH achieved precisely the kind of attitude shift that TCMLH was designed to achieve: they internalized the value of health engagement, that is, actively pursuing better health and well-being. [20][21][22] In fact, it might be more appropriate to speak of two distinct values that were communicated through the programme. First is the importance of self-care, which, for some participants, may have challenged the stoic values internalized during military service [23][24][25] and/or other life experiences. Second is the idea of 'taking charge' of one's health and healthcare, which invokes the value of self-reliance and subversively reframes it as enthusiastic engagement in, rather than stoic avoidance of, care. [26][27][28] In other words, TCMLH appears to have promoted several attitude shifts in its participants, challenging some values that Veterans held and reframing others. We recommend that healthcare systems seeking to implement TCMLH-style groups tailor the content and style of such groups in a way that acknowledges the historically and culturally specific meaning(s) of engaging in one's health common among the patient population(s) they serve.
Another key finding is that, for some individuals, TCMLH may serve as a gateway to a healthier lifestyle, in effect working as a quasi-coaching intervention. Given that more than half of our interviewees participated in a shorter, six-session version of TCMLH ( Our findings carry implications not only for the VHA but also for other healthcare organizations that may be interested in implementing novel approaches to empowering and supporting patients in the pursuit of health and well-being. While TCMLH is a VHA group targeting Veterans, it integrates broadly applicable principles and thus can serve as a promising framework for empowering patients to pursue greater health and well-being, as well as a way to introduce patients to the principles of patient-centred care and patient empowerment. Other healthcare systems may consider using TCMLH as a model for developing and implementing their own peer-led, group-based well-being programmes, tailored to the needs and characteristics of the patient populations that they serve. VHA's experience also suggests that offering such programmes in a virtual format may be a feasible and desirable innovation.

AUTHOR CONTRIBUTIONS
Ekaterina Anderson was responsible for the conceptualization, evaluation design, data collection, data analysis and writing of the original draft. Kelly Dvorin was involved in conceptualization, evaluation design, data collection and data analysis. Bella Etingen was involved in conceptualization and evaluation design. Anna M.
Barker was involved in conceptualization, project administration, evaluation design and data curation. Zenith Rai was involved in data collection, visualization and data analysis. Abigail N. Herbst was involved in evaluation design and data curation. Reagan Mozer was involved in study design. Rodger P. Kingston (Veteran consultant) was involved in conceptualization, evaluation design and data analysis. The senior author (Barbara G. Bokhour) was responsible for funding acquisition, supervision, conceptualization and evaluation design. All authors were involved in the review and editing of the manuscript drafts, have approved the final version to be published and agreed to be accountable for all aspects of the work.