Veteran Cultural Competence Training: Initial Effectiveness and National-Level Implementation
Abstract
Objective:
Because service professionals often lack cultural competence in working with veterans, veterans often perceive such professionals as “not understanding.” The authors developed, evaluated, and implemented Veteran Cultural Competence Training (VCCT), combining educational and experiential components in an in-person training focused on building awareness, knowledge, and skills to better work with veterans.
Methods:
Study 1 was a type 1 effectiveness-implementation hybrid trial examining VCCT effectiveness in a sample of social service professionals (N=41) compared with a matched comparison group (N=41) via the Multicultural Counseling Self-Efficacy Scale–Veteran Form (MCSE-V) instrument. In study 2, the authors used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to conduct a type 2 effectiveness-implementation hybrid trial and implemented VCCT with an expanded population (N=312) during eight training sessions in three U.S. states.
Results:
Results from study 1 indicated that VCCT significantly increased self-efficacy of trainees in veteran cultural competence compared with the matched group (p<0.001). In study 2, the RE-AIM framework highlighted the importance of building coalitions and utilizing implementation facilitation to maintain fidelity. The within-group effectiveness of VCCT was statistically significant and maintained across settings and professions (p<0.001), and trainees were satisfied with VCCT. Maintenance analysis revealed expansion of VCCT after implementation in terms of the number of training sessions (N=9), regions hosting the training (N=5), staff hired (N=13), and trainee applications (N=1,018).
Conclusions:
VCCT effectively increases self-efficacy in veteran cultural competence. Gains appeared across different professions, demographic characteristics, and locations. Participation in VCCT may increase professionals’ competence in understanding veteran culture, thereby potentially improving veteran services.
HIGHLIGHTS
•
Veterans often feel “othered” by their civilian communities and perceive that veteran services professionals are not understanding their experiences.
•
The authors developed, assessed, and evaluated the effectiveness and implementation of Veteran Cultural Competence Training (VCCT), a daylong training developed by combat veterans to increase competence in veteran culture among health and nonhealth professionals.
•
The results of this study suggest that VCCT increases self-efficacy in veteran cultural competence among professionals across different professions, and the skills gained persisted to a 1-month follow-up.
•
Results of maintenance analysis indicated vast expansion of VCCT after its implementation.
Currently, 19 million veterans reside in the United States, including 4 million who exited the military after 9/11 (1, 2). During their transition to civilian life, veterans face many difficulties with social relations, employment, community involvement, and health (3–6). Resolving these difficulties requires that veterans receive community assistance and that service providers understand their experiences. Many veterans describe feeling disconnected from civilian communities (7) and perceive civilians as “not understanding” (8, 9). Similarly, civilians often hold harmful stereotypes about veterans (e.g., that veterans are more likely to be dangerous or to have a mental illness [10]) and lack an understanding of military culture (8, 11). The resulting divide magnifies veterans’ difficulties by driving disconnection (7), prejudicing hiring decisions (10, 12), and hindering access to health care (9, 13).
Veteran Cultural Competence
Recently, U.S. society has become increasingly aware of the importance of cultural competence. Professional cultural competence is an ability to use awareness of attitudes, beliefs, knowledge, and skills to provide effective services and establish an optimal environment for persons from various cultural backgrounds (14). Within health care settings, cultural competence is associated with favorable outcomes, including improved patient satisfaction, better treatment engagement, and lower attrition (15, 16).
Although traditionally conceptualized within the context of racial and ethnic culture (14), cultural competence has recently expanded to include military/veteran culture (8). Like all cultures, veterans share a “code of manners, norms of behavior, belief systems, dress, and rituals” (17). Effective engagement with veterans often requires an understanding of and respect for such aspects of identity. However, competence in veteran culture is lacking among many professionals (8, 9, 11, 18–20). As a result, up to 95% of veterans with health problems prefer to receive treatment from veteran providers (9).
Cultural Competence Training
Cultural competence can be increased through training (21, 22). Such training addresses three domains of cultural competence: awareness, knowledge, and skills (14, 16, 21, 22). To foster awareness, trainees examine their own beliefs and attitudes toward culturally diverse individuals. To enhance knowledge, trainees learn about the target culture’s language, customs, and beliefs. Finally, to increase skills, trainees actively develop and practice appropriate strategies (e.g., communication skills and engagement strategies) (15, 16, 23). Some organizations have created training programs in veteran cultural competence, but these programs often have significant shortcomings, and some are no longer offered (24). Most existing programs consist solely of watching online videos with no in-person or skill-based components (25, 26), some do not offer continuing education units (CEUs), and most have no evidence base (25–27).
Veteran Cultural Competence Training (VCCT)
VCCT was developed by experts with significant experience serving in the military, being a military family member, or working closely with veterans in health care, business, or academia. The senior developer/trainer (SD/T) served for 20 years in the U.S. Army as a senior infantry officer, with four deployments to Afghanistan, before retiring from military service and serving as a U.S. Department of Veterans Affairs (VA) psychologist and education director. The VCCT developers reviewed the literature on cultural competence and effective pedagogical methods (28, 29), completed extensive coursework with leading cultural competence experts (14), conducted interviews with veterans (30), and attended existing veteran/military cultural competence training sessions (25, 26).
As a result, VCCT combines educational and experiential components, including theater performances, to create an in-person, immersive, daylong, and manualized training program focused on building awareness, knowledge, and skills to better work with veterans. (The components of VCCT are shown in the online supplement to this article.) The SD/T provided instruction during all training sessions. The sessions were offered at no cost to trainees. Studies were approved by Teachers College, Columbia University.
Studying VCCT
This article reports on the design and outcomes of two VCCT studies. Study 1 was a type 1 effectiveness-implementation hybrid trial (31) that examined VCCT effectiveness in a sample of professionals working in social services. We hypothesized that trainees’ self-efficacy in veteran cultural competence would significantly increase compared with that of professionals in a matched comparison group.
Study 2 was a type 2 effectiveness-implementation hybrid trial (31). Its first aim was to determine the effectiveness of VCCT with a larger population. We hypothesized that attending VCCT would significantly increase professionals’ self-efficacy in veteran cultural competence and that the increases would not differ by profession. The second aim was to determine the feasibility and potential utility of a partner-engaged plan for implementing VCCT. To facilitate national VCCT expansion, the VCCT staff divided the nation into 10 regions (see the online supplement ). The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework guided the second aim (32).
Methods
Participants
Study 1.
In May 2017, Syracuse University’s Institute for Veterans & Military Families (33), a national organization focused on improving community-based social service delivery for veterans, invited employees and partners to a VCCT session. Overall, 55 individuals signed up, 41 of whom completed VCCT. Trainees were professionals who provided social services (e.g., housing, employment, food assistance) to veterans (34). Participants in the comparison group (N=63) were recruited through e-mails to organizations that also provided social services to veterans. To ensure approximate equivalence at baseline, we used propensity score matching with the Fuzzy Python procedure in SPSS (35) to match 41 of the comparison group professionals to the VCCT trainees according to baseline self-efficacy in veteran cultural competence, gender, education level, and veteran status. After the matching, any between-group differences were considered training effects, analogous to a randomized design (36). Most participants were women (57%, N=47), were nonveterans (51%, N=42), and had a master’s degree (54%, N=44). No significant differences between the two groups were identified at baseline (see the online supplement ).
Study 2.
Eight VCCT sessions (during 2018–2020) were conducted with 312 trainees (Table 1). Most trainees were women (71%), were nonveterans (77%), had a master’s degree (49%), and worked as health services professionals (46%). The trainees were recruited through social media, professional associations, and organizational invitations. For the first four training sessions, Teachers College, Columbia University, provided external approval and then transitioned responsibility to the VA for all subsequent sessions, with the VA being responsible for health services professionals’ receiving CEUs (37).
| | Baseline | Post-VCCT | 1-month follow-up | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Characteristic | MCSE-V score (M±SD) | N | % | MCSE-V score (M±SD) | N | % | MCSE-V score (M±SD) | N | % |
| Gender | | | | | | | | | |
| Man | 6.8±1.7 | 91 | 29 | 7.9±1.0 | 79 | 28 | 7.9±.9 | 58 | 32 |
| Woman | 5.9±2.0 | 221 | 71 | 7.7±1.1 | 200 | 72 | 7.7±1.0 | 125 | 68 |
| Veteran | | | | | | | | | |
| No | 5.8±1.9 | 239 | 77 | 7.5±1.1 | 216 | 77 | 7.6±.9 | 143 | 78 |
| Yes | 7.3±1.5 | 73 | 23 | 8.4±.7 | 63 | 23 | 8.4±.9 | 40 | 22 |
| Education level (degree) | | | | | | | | | |
| Associate’s, B.A., or B.S. | 6.2±2.1 | 115 | 37 | 7.9±1.0 | 104 | 37 | 7.9±.9 | 64 | 35 |
| Master’s | 6.2±1.9 | 152 | 49 | 7.8±1.1 | 141 | 51 | 7.7±1.1 | 89 | 49 |
| Doctoral | 5.7±1.6 | 45 | 14 | 7.2±1.4 | 34 | 12 | 7.7±.8 | 30 | 16 |
| Professional sector | | | | | | | | | |
| Health services | 6.1±1.9 | 144 | 46 | 7.7±1.1 | 125 | 45 | 7.7±1.0 | 82 | 45 |
| Social services | 6.5±1.8 | 89 | 29 | 7.8±1.1 | 80 | 29 | 7.9±1.0 | 51 | 28 |
| College faculty | 5.7±2.1 | 50 | 16 | 7.8±.9 | 47 | 17 | 7.8±.9 | 34 | 19 |
| Government or business | 6.1±2.4 | 29 | 9 | 7.3±1.3 | 27 | 10 | 7.7±1.2 | 16 | 9 |
| Total | 6.1±1.9 | 312 | 100 | 7.7±1.1 | 279 | 100 | 7.8±1.0 | 183 | 100 |
a
Ns for later time points do not add up to the total at baseline because of attrition. VCCT, Veteran Cultural Competence Training.
Measures
To assess trainees’ confidence in having skills in veteran cultural competence, the trainees completed the Multicultural Counseling Self-Efficacy Scale–Veteran Form (MCSE-V), which is a modified version of the MCSE–Racial Diversity Form (MCSE-RD) (23). The MCSE-RD contains 37 items that assess trainees’ self-perceived efficacy to perform counseling skills presumed to foster positive therapy experiences with racially diverse clients. Participants scored items on a Likert scale ranging from 0, no confidence at all, to 9, complete confidence.
Sheu and colleagues (38) conducted a confirmatory factor analysis of the MCSE-RD and reported that a bifactor model produced the best fit, suggesting the existence of a generic helping skills factor (indicated by the mean total score) as well as the three multicultural-specific factors of multicultural intervention, multicultural assessment, and multicultural counseling session management. The total score correlated significantly with theoretically relevant variables (e.g., multicultural counseling competencies, general counseling self-efficacy, and multicultural training experiences) (23).
To create the MCSE-V, the MCSE-RD was adapted to be specific to veterans and applicable to various professionals. For example, the MCSE-RD item “encourage the client to take an active role in counseling” was modified to “encourage the veteran to take an active role in the professional relationship.” Because the intended population extends beyond mental health providers, the multicultural assessment items (e.g., “interpret standardized tests”) were excluded. The resulting MCSE-V consisted of 26 items.
In preparation for study 1, we evaluated the factor structure of the MCSE-V by using results from professionals and graduate students (N=90) and similar hypotheses and procedures described by Sheu and colleagues (38). Confirmatory factor analysis was conducted in Mplus, version 7.3 (39). We found that the bifactor model gave the best fit (see the online supplement ). The Cronbach’s alpha was 0.98 for study 1.
Study 1 Procedures
VCCT trainees.
After receiving an e-mail invitation to attend VCCT, trainees completed the measures online (baseline measurement). Trainees then completed online modules focused on military culture provided by the PsychArmor Institute (26) to ensure a minimum level of veteran cultural competence before the in-person component. Additional online surveys were completed after the PsychArmor online training (post-PsychArmor hereafter) and after the VCCT sessions.
Comparison group.
The participants in the comparison group did not participate in training in veteran cultural competence. They received invitations to complete the baseline survey and post-VCCT survey. Because administrations of the post-PsychArmor and post-VCCT surveys to the VCCT trainees had only a 1-day interval, the data from the comparison group’s post-VCCT surveys were used as proxies for the post-PsychArmor surveys. This design facilitated analysis with the hierarchical linear modeling (HLM) program and minimized survey burden on the comparison group.
Study 2 Procedures
Trainees completed the baseline survey and PsychArmor online training from study 1 before attending the in-person component. After VCCT, trainees completed the post-VCCT and 1-month follow-up surveys.
Study 2 Implementation Strategies
A bundle of implementation strategies were developed according to the Quality Enhancement Research Initiative Implementation Roadmap (40, 41) and the Expert Recommendations for Implementing Change taxonomy (42). Strategies were selected to address barriers at each phase (see the online supplement ).
Preimplementation.
To build a working coalition and obtain formal commitments to the VCCT (42), VCCT staff selected regional partners consisting of colleges, a VA medical center, and a business headquarters. The partners were responsible for marketing, hosting, and coordinating logistic requirements. The VCCT staff formalized contracts and completed necessary paperwork.
Implementation.
To ensure ongoing training (42), the VCCT staff worked with partners to identify and select small-group facilitators (SGFs). Optimal SGFs were veterans or family members of a veteran and had experience providing professional services (e.g., peer support specialist, social worker or counselor, or psychologist). All SGFs attended SGF training and orientation (43).
To facilitate VCCT implementation (44), the VCCT SD/T and administrative officer served as external facilitators for each iteration by developing, distributing, and ensuring adherence by partners to the implementation tool kit, which included the VCCT training manual and execution checklist (43). The facilitation included audit and feedback activities during weekly meetings leading up to each iteration. With the execution checklist as a guide, the facilitators conducted assessments of preparatory activities and provided feedback to the partners.
Sustainment.
To increase demand for VCCT (42) and access new funding for conducting VCCT sessions (42), the VCCT staff shared updates regarding the VCCT with current partners, VA national leadership, local and state leaderships, and potential future partners. In the updates, the VCCT staff highlighted the status regarding VCCT implementation and effectiveness variables. We conducted analysis of implementation costs, including personnel, materials, facilities and food, technology, and travel, to identify resources for further VCCT expansion.
RE-AIM
The RE-AIM framework allowed the staff to adapt to the complexities resulting from a multipartner collaborative endeavor across many regions. Reach was assessed by calculating the numbers and types of professionals who attended each training session, with the goal of at least 27 trainees per session, with nine per squad (45). The priority profession for VCCT enrollment was health services (goal of 50% enrollment), with the remaining trainees evenly distributed between social services, college faculty, and government or business professions.
Effectiveness was assessed with HLM, version 8, by using trainee-level MCSE-V total scores at level 1. The Cronbach’s alpha was 0.98 for study 2. Gender, veteran status, education level, partner type, training session, profession type, and the external authority approving the curriculum were added as predictors at level 2. Adoption was assessed by counting the number of training sessions per year per region, as well as the number of funded VCCT staff.
Implementation was assessed by three dimensions (46). First, to assess fidelity, we developed fidelity trackers that assessed adherence to the following implementation factors: an external authority approved the curriculum, the execution checklist was utilized by partners, and the SD/T provided instruction and supervised SGFs. Second, quality of content delivery was assessed with the prompt, “The learning activities and/or materials were effective in helping me learn the content.” Third, participant responsiveness was assessed with two prompts: “Overall, I was satisfied with this learning activity” and “I would recommend this training course to others.” Responses to all prompts were scored on a 5-point Likert scale (ranging from strongly disagree, 1, to strongly agree, 5). Maintenance was assessed after the last iteration to determine the number of continued training sessions, regions, funded VCCT staff, and professionals who signed up to attend VCCT.
Data Analysis
HLM, version 8 (47), was used to assess the effect of training on changes in MCSE-V total scores in intent-to-treat analyses. To test for a linear pattern of change, a static time term was used for each time point at level 1. Time was centered at the respective time point being assessed so that the parameter for the intercept would represent MCSE-V scores at this time point (48). For study 1, a dummy-coded variable for group and MCSE-V baseline values were added at level 2. Effect size was calculated by using procedures outlined by Feingold (49), with effect sizes being equivalent to Cohen’s guidelines (50–52).
Pilot results from 54 professionals who attended the initial VCCT session, in July 2016, informed power analyses. Trainees in the pilot study completed surveys (see the online supplement ) at baseline, post-VCCT, and at 1-month follow-up, with analyses suggesting that trainees showed statistically significant increases in self-efficacy in veteran cultural competence from baseline to follow-up (β=0.83, t=14.77, df=50, p<0.001, Cohen’s d=0.88, indicating a large effect size). Study 1 power analyses were conducted with a between-group (matched-pairs) test in G*Power 3 (53), with α=0.05, power=0.95, and a medium effect size. Results suggested that a minimum sample of N=54 was needed to achieve sufficient statistical power; the sample size in study 1 was N=82 and considered adequate.
Results
Study 1
The main effect of VCCT significantly differentiated the trainee group from the comparison group, indicating a 0.27-point increase in self-efficacy in veteran cultural competence at the post-PsychArmor survey (β=0.27, t=2.49, df=79, p<0.05) and a 0.63-point increase at the post-VCCT survey (β=0.63, t=3.37, df=79, p<0.001) (Table 2). The group × time interaction effect testing the primary outcome variable of MCSE-V total score over time (Table 2 and Figure 1) exhibited a statistically significant positive linear trend (β=0.37, t=4.23, df=79, p<0.001, Cohen’s d=0.56, indicating a medium effect), indicating that VCCT trainees had a significant increase in MCSE-V scores compared with those in the comparison group.
| | Baseline | Post-PsychArmor online training | Post-VCCT | |||
|---|---|---|---|---|---|---|
| Parameter | β | SE | β | SE | β | SE |
| Difference in MCSE-V scores | | | | | | |
| Intercept | 7.51 | .04** | 7.48 | .07** | 7.45 | .11** |
| Groupb | −.10 | .05 | .27 | .11* | .63 | .27** |
| MCSE-V baseline score | .99 | .02** | .84 | .04** | .69 | .07** |
| Group × time interaction | | | | | | |
| Intercept | | | | | −.03 | .04 |
| Groupb | | | | | .37 | .09** |
| MCSE-V baseline score | | | | | −.15 | .04** |
a
MCSE-V, Multicultural Counseling Self-Efficacy Scale–Veteran Form.
b
The following analysis codes were used: VCCT, 1; comparison group, 0.
*p<0.05, **p<0.001.
FIGURE 1. Scores on the MCSE-V instrument for VCCT trainees (N=41) versus participants in the comparison group (N=41) in study 1a
aMCSE-V, Multicultural Counseling Self-Efficacy Scale–Veteran Form (scores range from 0 to 9, with 0 indicating no confidence at all and 9 indicating complete confidence); PsychArmor, PsychArmor online training; VCCT, Veteran Cultural Competence Training.
Study 2
Results from the reach analysis indicated that a mean±SD of 39.0±16.8 trainees attended each training session. Two sessions did not meet the enrollment goal of 27 trainees: Charlotte, North Carolina (October 2018) and Fordham University, New York City (April 2019) (see the online supplement ). For the Charlotte location, a contributing factor may have been that the VCCT staff and partner started enrolling participants only 20 days before the session, compared with the average of 46.9±22.3 days for all training sessions. The Fordham session may have occurred too close to the previous VCCT session at the same location (i.e., within 4.5 months).
Most of the participants were health services professionals (46%, N=144). Before the VA offered CEUs, 43% (N=70 of 162) of the trainees were from health services professions, with the percentage increasing to 49% (N=74 of 150) for all subsequent training sessions.
Government or business professionals were underrepresented, accounting for only 10% (N=29) of trainees across all sessions, compared with social services (29%, N=89) and college faculty (16%, N=50). The partner type (college [N=6], VA medical center [N=1], or business headquarters [N=1]) significantly affected the composition of professionals attending VCCT (χ2=16.19, df=6, p<0.05). Of note, 24% (N=11 of 46) of the trainees at a session hosted at a business headquarters were government or business professionals, compared with only 7% (N=19 of 266) of trainees who were government or business professionals at all other sessions.
For the effectiveness component within the RE-AIM framework, trainees had statistically significant increases in MCSE-V total score from baseline to follow-up (within group: β=0.69, t=4.06, df=304, p<0.001, Cohen’s d=0.72, indicating a medium effect) (Table 3). Education level, partner type, training iteration, and profession did not have any significant effect on MCSE-V scores. Regarding veteran status, veteran trainees’ MCSE-V scores were 1.29 points higher than the scores of nonveterans at baseline (β=1.29, t=6.02, df=304, p<0.001). At the 1-month follow-up, however, veterans scored only 0.76 points higher than nonveterans. Although the difference between veterans and nonveterans at the follow-up was still statistically significant, a significant decrease in scores among veterans relative to nonveterans indicated that the effect of veteran status significantly declined (β=−0.26, t=2.19, df=304, p<0.05).
| | Baseline | Post-VCCT | 1-month follow-up | |||
|---|---|---|---|---|---|---|
| Parameter | β | SE | β | SE | β | SE |
| Difference in MCSE-V scores | | | | | | |
| Intercept | 6.66 | .29*** | 7.35 | .18*** | 8.03 | .20*** |
| Gendera | −.40 | .20* | −.10 | .13 | .21 | .14 |
| Veteran statusb | 1.29 | .21*** | 1.03 | .14*** | .76 | .15*** |
| Education levelc | −.12 | .15 | −.15 | .09 | −.17 | .10 |
| Partnership typed | −.08 | .14 | −.03 | .09 | .03 | .10 |
| N of training sessions (reference: 1 session) | −.05 | .11 | −.02 | .07 | .02 | .08 |
| Professional sectore | −.13 | .10 | −.10 | .06 | −.07 | .07 |
| Training approval authorityf | .21 | .61 | .01 | .38 | −.18 | .44 |
| Group × time interaction | | | | | | |
| Intercept | | | | | .69 | .17*** |
| Gendera | | | | | .31 | .11** |
| Veteran statusb | | | | | −.26 | .12* |
| Education levelc | | | | | −.03 | .08 |
| Partnership typed | | | | | .06 | .08 |
| N of training sessions (reference: 1 session) | | | | | .03 | .07 |
| Professional sectore | | | | | .03 | .06 |
| Training approval authorityf | | | | | −.19 | .37 |
a
The following analysis codes were used: woman, 1; man, 0.
b
The following analysis codes were used: veteran, 1; nonveteran, 0.
c
The following analysis codes were used: doctorate degree, 2; master’s degree, 1; associate’s, B.A., or B.S. degree, 0.
d
The following analysis codes were used: business partnership, 2; U.S. Department of Veterans Affairs (VA) partnership, 1; college partnership, 0.
e
The following analysis codes were used: government and business, 3; college faculty, 2; social services, 1; health services, 0.
f
The following analysis codes were used: VA or Teachers College, 1; Columbia University, 0.
*p<0.05, **p<0.01, ***p<0.001.
At baseline, women trainees had significantly lower scores on the MCSE-V, by 0.40 points, compared with men (β=−0.40, t=2.00, df=304, p<0.05). However, we did not detect a significant gender difference at the 1-month follow-up because women trainees showed a significant increase in their MCSE-V score compared with men (β=0.31, t=2.76, df=304, p<0.01). Of note, the baseline scores for nonveteran women were significantly lower than for all other trainees (t=5.56, df=310, p<0.001). However, their scores significantly increased from 5.67±1.97 at baseline to 7.60+0.99 at the 1-month follow-up (β=1.05, t=14.15, df=191, p<0.001, Cohen’s d=1.07, indicating a large effect).
VCCT adoption increased with each fiscal year (FY) (2018, N=1; 2019, N=3; and 2020, N=4 sessions). However, training was hosted only in three of 10 regions. The number of funded VCCT staff increased from one in 2018 to two in 2019 and 2020.
Regarding fidelity, the variable of external authority was not statistically significant, showing no effect on mean MCSE-V scores. The SD/T provided instruction and supervised SGFs for each iteration. The VCCT staff used an execution checklist with each partner during weekly meetings leading up to each iteration. To assess the quality of training delivery, we used post-VCCT survey data from trainees (N=131) who attended one of the four sessions in FY2020. The results showed that 90% (N=118) of the trainees either agreed or strongly agreed that the activities or materials were effective in helping them learn the content. For participant responsiveness, 93% (N=122) of the trainees either agreed or strongly agreed that they were satisfied with the training, and 95% (N=124) agreed or strongly agreed that they would recommend the training to others.
All sessions scheduled for FY2021 were canceled because of the COVID-19 pandemic. However, maintenance analysis showed vast expansion of VCCT for FY2022, with the number of sessions increasing (N=9), regions implementing VCCT expanding (N=5), VCCT staff growing (N=13), and professionals who signed up to attend VCCT greatly increasing (N=1,018).
Discussion
The results of study 1 suggest that VCCT significantly increased the self-efficacy and confidence of trainees in veteran cultural competence compared with a matched comparison group. Completing the PsychArmor online training yielded initial improvements in the MCSE-V total score, but the training had its full effect after completion of the in-person component. These findings are consistent with previous recommendations that training sessions should address a combination of awareness, knowledge, and skills (15, 16, 23).
The RE-AIM framework in study 2 helped to highlight the importance of building working relationships with different partners and utilizing implementation facilitation to maintain fidelity across sessions. Offering CEUs and alternating the type of partners hosting the training enabled the VCCT staff to attract target trainees. The results of study 2 show that the effectiveness of VCCT was maintained throughout its implementation. Trainees were satisfied with VCCT. An assessment of maintenance showed that VCCT has the potential to continue to expand and assist even more professionals.
Women make up most professionals within certain health service fields (e.g., mental health counselors [76%], social workers [73%], nurses [87%], and psychologists [75%]) (54), but they comprise only 17% of the active duty military (55). Therefore, an important finding from study 2 was the significant improvement in the MCSE-V total score among both women and nonveterans, with most of the trainees (62%, N=192) being nonveteran women.
The present research had many strengths. The findings should, however, be interpreted within the context of a few limitations. First, although the quasi-experimental design provided opportunities to compare a group of VCCT trainees with a comparison group, the absence of randomization in study 1 increased the likelihood that unassessed confounding factors may have influenced the results. Second, the degree to which self-efficacy, as measured by the MCSE-V instrument, corresponds to behaviors reflective of veteran cultural competence in practice remains unclear. Research findings on the MCSE-RD (from which the MCSE-V was adapted), however, suggest that self-efficacy often correlates with theoretically meaningful constructs, including multicultural competence. Continued research should evaluate ratings from veterans receiving services from VCCT trainees to gauge improvements in cultural competence due to VCCT. Third, the studies evaluated trainees only immediately after the training (study 1) or at a 1-month follow-up (study 2). Therefore, future research should assess the long-term durability of the training. Last, because recruitment practices relied on partner-level dissemination of marketing materials, we could not estimate recruitment rates.
Conclusions
Our results suggest that VCCT effectively increases self-efficacy in veteran cultural competence among professionals providing veteran services. Gains in self-efficacy were observed across professionals, demographic characteristics, and veterans that persisted to the 1-month follow-up. Participation in VCCT may therefore help improve the services that professionals provide to veterans.
Supplementary Material
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Information & Authors
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Received: 21 July 2021
Revision received: 6 April 2023
Accepted: 17 April 2023
Published online: 9 August 2023
Published in print: January 01, 2024
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Competing Interests
Dr. Goodman is a consultant for Boehringer Ingelheim. The other authors report no financial relationships with commercial interests.
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