“I remember the skills we learned and put them into practice”: An Evaluation of a Peer Support Training Program for Veterans

Community-based organizations (CBOs) are critical sources of support for veterans. CBOs offer innovative and informed initiatives and are often nexuses that allow veterans and their allies to gather. Out of a commitment to veteran reintegration, Growing Veterans (GV), a veteran-founded CBO located in western Washington, created and implemented an evidence-based peer support training program (PST) for veterans and their allies. Building upon years of collaboration, GV partnered with the Veterans Health Administration (VHA) to conduct a formative evaluation of GV’s PST program, funded through the Bob Woodruff Foundation. The evaluation revealed that participants described the PST in largely positive ways and reported using learned skills with both veterans and nonveterans across their personal and professional lives. Specifically, participants reported learning tools through the PST that increased their patience, mindfulness, awareness, empathy, and confidence, resulting in improved interpersonal relationships and communications across multiple domains. The success of this community-engaged collaboration was due in part to the inclusion of veterans, allies, GV employees, and VHA evaluators throughout the evaluation, from grant applications to the final analysis. Using ethnographic methods of participant observation, in-depth interviews, focus groups, and surveys, VHA evaluators were able to gain a deep understanding of participants’ experiences of the PST as well as the program’s perceived usefulness. Community reintegration poses many challenges for veterans, yet community-based organizations (CBOs) can be critical sources of support (Crocker et al., 2014; Demers, 2011; Drebing et al., 2018; J.A. Gorman et al., 2018; L.A. Gorman et al., 2011; Sayer et al., 2010, 2014). Growing Veterans (GV) is a veteran-founded CBO committed to cultivating veteran reintegration and reducing isolation through farm-based and peer support initiatives with veterans and their civilian allies. GV’s vision is “to end the isolation that leads to veteran suicide” (Growing Veterans, 2021). To support this vision, GV developed an innovative, evidence-based peer support training program (PST). With funding from the Bob Woodruff Foundation (BWF), the PST curriculum was designed and piloted by a group of GV members, including veteran peers, mental health professionals, and educators. A mutual desire to improve reintegration resources led GV to partner with Veterans Health Administration (VHA) evaluators to conduct an independent evaluation of the PST via funding from the BWF. Introduction Reintegration challenges faced by servicemembers, including anxiety, depression, post-traumatic stress disorder, and substance abuse resulting from or exacerbated by combat exposure and transition stress, have been well documented in the literature (Amdur, 2011; Crocker et al., 2014; Hoerster et al., 2012; Sayer et al., 2011, 2014; Seal et al., 2007). Critical to mediating reintegration is that veterans learn how to negotiate norms in the communities to which they are returning or moving (Demers, 2011; Romaniuk & Kidd, 2018). Often these norms differ from what veterans were used to in the military (Cogan, 2016). Differences in cultural norms, a lack of preparation for what to expect after leaving the military, and the loss of a social network can all contribute to reintegration challenges for both servicemembers and their families. A growing body of reintegration research supports decreased social support as a major challenge for veterans (J.A. Gorman et al., 2018). To help ease servicemembers’ transitions, there has been a surge of reintegration program development over the past decade, especially in the nonprofit sector. However, evidence bases for such programs, rigorous evaluation to determine what programs provide for servicemembers, and evaluation of the programs’ impacts are often lacking. 1 Besterman-Dahan et al.: An Evaluation of a Peer Support Training Program for Veterans Published by Nighthawks Open Institutional Repository, 2021 Programming focused on community engagement can help ease postmilitary transitions. Community engagement within Western culture, however, has declined over the past 50 years, including downturns in overall participation in community organizations, volunteering, voting, and knowing one’s neighbors (Putnam, 1995). Given this decline, returning veterans are likely to find fewer partners in the community looking to engage with them, reducing the chance that they will find social support and ultimately contributing to the “military-civilian divide.” However, current data indicate a positive trend in veterans’ potential for social engagement. In comparison to their civilian counterparts, veterans are more likely to trust and talk with their neighbors, to participate and serve as leaders in civic organizations, and to be politically engaged (Tivald & Kawashima-Ginsberg, 2015). Veterans share a number of common values, including having a sense of community, wanting to give back, and wanting to be a part of something bigger than oneself. CBOs such as GV are important to veteran reintegration because they employ innovative community-building initiatives that involve peer support, which helps ease isolation and cultivate common ground between veterans and civilian communities. A Framework for Community Engagement: Collaboration between VHA and GV This evaluation of GV’s PST program stemmed from a previous collaboration between the VHA and GV. In 2014, the Veterans Affairs Office of Rural Health funded a VHA-led mixed-methods case study evaluation of GV in an effort to better understand the veteran health and reintegration outcomes of GV’s agricultural program (Besterman-Dahan et al., 2018). At that time, GV was in the process of developing its PST program (Brown et al., 2016). With funding from the BWF, GV went on to create its innovative PST based on best practices and elements delineated by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCOE) as essential to a successful military/ veteran peer support program (Money et al., 2011). GV’s PST is a 3-day workshop in which veterans and allies of veterans (family members, care providers, people who work with veterans) learn and practice the skills necessary to be effective peer supporters for other veterans. During 2016 and 2017, GV conducted four PST sessions, resulting in 54 trained peer supporters who returned to their veteran service organizations (VSOs) and communities across the country to subsequently support over 1,400 veteran peers (BestermanDahan et al., 2019). In follow-up surveys, trainees (n = 24) overwhelmingly agreed that the PST encouraged their own self-care as well as increased their confidence in recognizing PTSD symptoms, serving as peer supporters, and making appropriate referrals to mental health care providers. GV then partnered with the VHA evaluators to develop a proposal for continued funding from BWF for (a) GV to continue its PST program and (b) VHA evaluators to conduct a rigorous, independent program evaluation of the GV PST from 2017 to 2019. This evaluation used a community-engaged framework. In public health literature, community engagement has been broadly defined as “involving communities in decision-making and in the planning, design, governance and delivery of services” (Swainston & Summerbell, 2008, p. 11). Community engagement activities can take many forms and are usually described in terms of five levels of engagement (from least to most engaged): information-giving, consultation, joint decision-making, acting together, and supporting independent community interests (Wilcox, 1994). In this evaluation, the VHA evaluators implemented community engagement through their partnership with GV, continued communication with GV, and periodic feedback between VHA and GV. In addition, veterans were included as participants in the PST itself and as participants in the completion of the evaluation, and one coauthor of this article is a veteran. Methods VHA evaluators conducted an independent formative evaluation of the PST program using a community-engaged framework. The project was designated a quality assurance activity by the local VHA Research and Development Committee; institutional review board approval was not required. Evaluators used a mixed-method design that employed ethnographic methods of participant observation, in-depth interviews, focus groups, and surveys. Ethnography is a hallmark of anthropological research that is used to explore the lived experiences of others. The VHA evaluation data collection team consisted of two PhD-level applied anthropologists, both with extensive knowledge and applied research experience utilizing ethnographic methods in community-based research with veterans. The study’s principal investigator, an applied medical 2 Journal of Community Engagement and Scholarship, Vol. 13, Iss. 4 [2021], Art. 2 https://digitalcommons.northgeorgia.edu/jces/vol13/iss4/2 anthropologist, had worked in collaboration with GV since 2014. The PST program was evaluated for its content, delivery, usefulness, quality, and alignment with VSO values. The evaluation team also examined barriers and facilitators to attending the training and influence of PST on participants’ knowledge, attitude, and intention. The program’s implementation was also assessed via a post training focus group and survey with PST trainers. Collaboration is central to community engagement and was crucial to the success of this program evaluation. GV staff and the evaluation team worked closely with one another from proposal development through implementation of the evaluation. This collaboration began early. The VHA collaborated with GV in obtaining funding to both run the PST program and conduct a complementary formative evaluation. Evaluators facilitated a continuous cycle of feedback by conducting ongoing discussions via weekly team meetings before each peer support workshop, in addition to meetings during each workshop while on breaks, and after each session closed for the evening. Upon completion of each PST workshop, the evaluation team and GV staff would meet for a brief focus group, which also led to an organic process of debriefing with all team members and additional debriefing among the evaluation team. Evaluators gathered feedback from workshop participants through observation, conversations with participants, and focus group results, and they both shared this feedback with GV staff daily and included it in final reports. Open dialogue and transparency built trust between the evaluation team and GV staff. The return on the investment of time spent in debrief sessions, staff focus groups, and informal conversations during each workshop allowed PST trainers to make small course adjustments in real time or in preparation for the following workshop. Investigating and conducting evaluation and research with vulnerable communities demands the use of specific methods that not only engage the scholars involved but also protect the well-being and livelihoods of target populations (PachecoVega & Parizeau, 2018). Ethnography as a research methodology offers a unique opportunity to understand social phenomena that occur within vulnerable populations while maintaining a rigorous research process (McGranahan, 2014; Warren, 2014). Engaged ethnography also requires researchers to pay attention to the relationships they are building with the communities they are working alongside. Relationship building and collaboration with the GV community, including PST participants, were critical components of the evaluation. Of additional importance when employing community-engaged ethnographic methods is acknowledgment of the power dynamics intrinsic to ethnographic projects and writing. Methodological approaches inherent to ethnographic research allow researchers to engage with both the academic concerns of their discipline and the broader structural and cultural factors that perpetuate systems of inequality (Pacheco-Vega & Parizeau, 2018). The nature of the PST required trust between all those present at the sessions hosted by GV. Because the evaluators were active participants in the PST during data collection, they held the safety and needs of PST participants as a top priority. The PST data collection process allowed participants to decide whether or not they welcomed the presence of the evaluators at their sessions. This element of choice was especially important during parts of the curriculum when participants were invited to share their personal experiences with one another, often revealing sensitive information related to their personal accounts with traumatic experiences. Evaluators and GV staff carefully prioritized gathering participants’ consent with regard to the attendance of the project team during the PST, frequently checking in with participants individually, during group exercises, and via anonymous qualitative feedback gathered from survey data. There were no instances in which participants asked for the project team not to participate with them in the PST. During the 2017–2019 evaluation period, GV hosted four PST sessions, one each in February, April, September, and October of 2018. Each cohort of PST participants completed a pretraining focus group and survey, a post training focus group and survey, and an interview and survey 90 days after the conclusion of training. PST trainers were asked to participate in a post training focus group or debriefing and to complete a post training survey after each PST cohort. Table 1 summarizes the sources of data gathered from participants. Focus Groups A total of eight focus groups were conducted with PST participants. Four focus groups (one per cohort) were conducted with PST participants (one per cohort) prior to starting the program to determine participants’ baseline knowledge of peer support and their expectations for the 3 Besterman-Dahan et al.: An Evaluation of a Peer Support Training Program for Veterans Published by Nighthawks Open Institutional Repository, 2021 training. Four focus groups (one per cohort) were conducted with PST participants immediately after training (one per cohort) to elicit their thoughts and reflections on the overall PST as well as the perceived usefulness, facilitators and barriers to understanding, and influence of the training. A post training focus group was also conducted with PST trainers to elicit their reactions to and reflections on the program. Focus groups were either led or co-led by members of the project team, one of whom served as focus group moderator while another team member took notes. Focus groups were audio-recorded with permission, and salient themes from the focus groups were identified and grouped for analysis. 90-Day interviews. Fourteen participants spanning all four cohorts were interviewed 90 days after their PST using a semi structured, in-depth interview protocol. All participants had agreed to be contacted for a 90-day interview at the original training. Interviews were conducted via telephone and recorded with verbal permission. Salient themes were identified and grouped for analysis. Participant observation. Participant observation is an ethnographic research method used to gain a holistic and in-depth understanding of how individuals and communities “describe and structure their world” (Creswell, 2014, p. 207). In a traditional sense, this usually entails the researcher engaging in the lives of the research participants for a long period of time, utilizing data collection activities such as direct observation, interviewing, document analysis, reflection, analysis, and interpretation. With the development of faster approaches to qualitative inquiry, participant observation can be successfully conducted over shorter periods of time while still meeting rigorous academic research standards of thorough data collection, analysis, and reporting. Following anthropological methods, field notes were taken during participant observation, compiled, and analyzed. Evaluation team members participated in all PST activities in all four PST sessions, which allowed for reflection on the activities and modules. By participating in the PST, the project team was able to build rapport with other participants and gain additional insight through casual conversations about the PST activities. The project team took detailed field notes during all aspects of the PST, and evaluators carefully observed group dynamics, emotions, and environmental stimuli throughout the PST and evaluation process. For instance, participants engaged in storytelling and sharing with each other throughout the PST, which sometimes put them in vulnerable positions. Both evaluators took care not to take notes at these moments, as doing so could be observed by the participants as insensitive and intrusive and likely would have resulted in a breach of trust between the researchers and the participants. In turn, this could have caused an unwelcome power imbalance in group settings. The evaluators were committed to active, participatory engagement in the PST alongside participants. When it felt inappropriate to take field notes, such as during the storytelling circles, evaluators took time to debrief with each other after the conclusion of the day’s session, actively reflecting on their experiences with the group, then writing their field notes. Surveys. The baseline surveys administered to PST participants collected data on their general demographics, history of military service, and VA service connection. Post-PST surveys asked participants to rate the PST modules and activities in terms of their usefulness and included 11 open-ended questions regarding the impact of the training, reactions to the training, and respondents’ intention to use the skills they learned during training. Similarly, the post-PST surveys for trainers asked respondents to rate the PST modules and activities in terms of their usefulness and rate their perceptions of how impactful the training was for participants. Table 1. Participant Sampling Frame Time Frame Participant focus groups Participant surveys Participant 90-day interviews


Introduction
Reintegration challenges faced by servicemembers, including anxiety, depression, post-traumatic stress disorder, and substance abuse resulting from or exacerbated by combat exposure and transition stress, have been well documented in the literature (Amdur, 2011;Crocker et al., 2014;Hoerster et al., 2012;Sayer et al., 2011Sayer et al., , 2014Seal et al., 2007). Critical to mediating reintegration is that veterans learn how to negotiate norms in the communities to which they are returning or moving (Demers, 2011;Romaniuk & Kidd, 2018). Often these norms differ from what veterans were used to in the military (Cogan, 2016). Differences in cultural norms, a lack of preparation for what to expect after leaving the military, and the loss of a social network can all contribute to reintegration challenges for both servicemembers and their families. A growing body of reintegration research supports decreased social support as a major challenge for veterans (J.A. Gorman et al., 2018). To help ease servicemembers' transitions, there has been a surge of reintegration program development over the past decade, especially in the nonprofit sector. However, evidence bases for such programs, rigorous evaluation to determine what programs provide for servicemembers, and evaluation of the programs' impacts are often lacking. 1 Programming focused on community engagement can help ease postmilitary transitions. Community engagement within Western culture, however, has declined over the past 50 years, including downturns in overall participation in community organizations, volunteering, voting, and knowing one's neighbors (Putnam, 1995). Given this decline, returning veterans are likely to find fewer partners in the community looking to engage with them, reducing the chance that they will find social support and ultimately contributing to the "military-civilian divide. " However, current data indicate a positive trend in veterans' potential for social engagement. In comparison to their civilian counterparts, veterans are more likely to trust and talk with their neighbors, to participate and serve as leaders in civic organizations, and to be politically engaged (Tivald & Kawashima-Ginsberg, 2015). Veterans share a number of common values, including having a sense of community, wanting to give back, and wanting to be a part of something bigger than oneself. CBOs such as GV are important to veteran reintegration because they employ innovative community-building initiatives that involve peer support, which helps ease isolation and cultivate common ground between veterans and civilian communities.

A Framework for Community Engagement: Collaboration between VHA and GV
This evaluation of GV's PST program stemmed from a previous collaboration between the VHA and GV. In 2014, the Veterans Affairs Office of Rural Health funded a VHA-led mixed-methods case study evaluation of GV in an effort to better understand the veteran health and reintegration outcomes of GV's agricultural program (Besterman-Dahan et al., 2018). At that time, GV was in the process of developing its PST program (Brown et al., 2016). With funding from the BWF, GV went on to create its innovative PST based on best practices and elements delineated by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCOE) as essential to a successful military/ veteran peer support program (Money et al., 2011). GV's PST is a 3-day workshop in which veterans and allies of veterans (family members, care providers, people who work with veterans) learn and practice the skills necessary to be effective peer supporters for other veterans. During 2016 and 2017, GV conducted four PST sessions, resulting in 54 trained peer supporters who returned to their veteran service organizations (VSOs) and communities across the country to subsequently support over 1,400 veteran peers (Besterman-Dahan et al., 2019). In follow-up surveys, trainees (n = 24) overwhelmingly agreed that the PST encouraged their own self-care as well as increased their confidence in recognizing PTSD symptoms, serving as peer supporters, and making appropriate referrals to mental health care providers. GV then partnered with the VHA evaluators to develop a proposal for continued funding from BWF for (a) GV to continue its PST program and (b) VHA evaluators to conduct a rigorous, independent program evaluation of the GV PST from 2017 to 2019.
This evaluation used a community-engaged framework. In public health literature, community engagement has been broadly defined as "involving communities in decision-making and in the planning, design, governance and delivery of services" (Swainston & Summerbell, 2008, p. 11). Community engagement activities can take many forms and are usually described in terms of five levels of engagement (from least to most engaged): information-giving, consultation, joint decision-making, acting together, and supporting independent community interests (Wilcox, 1994). In this evaluation, the VHA evaluators implemented community engagement through their partnership with GV, continued communication with GV, and periodic feedback between VHA and GV. In addition, veterans were included as participants in the PST itself and as participants in the completion of the evaluation, and one coauthor of this article is a veteran.

Methods
VHA evaluators conducted an independent formative evaluation of the PST program using a community-engaged framework. The project was designated a quality assurance activity by the local VHA Research and Development Committee; institutional review board approval was not required. Evaluators used a mixed-method design that employed ethnographic methods of participant observation, in-depth interviews, focus groups, and surveys. Ethnography is a hallmark of anthropological research that is used to explore the lived experiences of others. The VHA evaluation data collection team consisted of two PhD-level applied anthropologists, both with extensive knowledge and applied research experience utilizing ethnographic methods in community-based research with veterans. The study's principal investigator, an applied medical anthropologist, had worked in collaboration with GV since 2014. The PST program was evaluated for its content, delivery, usefulness, quality, and alignment with VSO values. The evaluation team also examined barriers and facilitators to attending the training and influence of PST on participants' knowledge, attitude, and intention. The program's implementation was also assessed via a post training focus group and survey with PST trainers.
Collaboration is central to community engagement and was crucial to the success of this program evaluation. GV staff and the evaluation team worked closely with one another from proposal development through implementation of the evaluation. This collaboration began early. The VHA collaborated with GV in obtaining funding to both run the PST program and conduct a complementary formative evaluation. Evaluators facilitated a continuous cycle of feedback by conducting ongoing discussions via weekly team meetings before each peer support workshop, in addition to meetings during each workshop while on breaks, and after each session closed for the evening. Upon completion of each PST workshop, the evaluation team and GV staff would meet for a brief focus group, which also led to an organic process of debriefing with all team members and additional debriefing among the evaluation team. Evaluators gathered feedback from workshop participants through observation, conversations with participants, and focus group results, and they both shared this feedback with GV staff daily and included it in final reports. Open dialogue and transparency built trust between the evaluation team and GV staff. The return on the investment of time spent in debrief sessions, staff focus groups, and informal conversations during each workshop allowed PST trainers to make small course adjustments in real time or in preparation for the following workshop.
Investigating and conducting evaluation and research with vulnerable communities demands the use of specific methods that not only engage the scholars involved but also protect the well-being and livelihoods of target populations (Pacheco-Vega & Parizeau, 2018). Ethnography as a research methodology offers a unique opportunity to understand social phenomena that occur within vulnerable populations while maintaining a rigorous research process (McGranahan, 2014;Warren, 2014). Engaged ethnography also requires researchers to pay attention to the relationships they are building with the communities they are working alongside.
Relationship building and collaboration with the GV community, including PST participants, were critical components of the evaluation. Of additional importance when employing community-engaged ethnographic methods is acknowledgment of the power dynamics intrinsic to ethnographic projects and writing. Methodological approaches inherent to ethnographic research allow researchers to engage with both the academic concerns of their discipline and the broader structural and cultural factors that perpetuate systems of inequality (Pacheco-Vega & Parizeau, 2018).
The nature of the PST required trust between all those present at the sessions hosted by GV. Because the evaluators were active participants in the PST during data collection, they held the safety and needs of PST participants as a top priority. The PST data collection process allowed participants to decide whether or not they welcomed the presence of the evaluators at their sessions. This element of choice was especially important during parts of the curriculum when participants were invited to share their personal experiences with one another, often revealing sensitive information related to their personal accounts with traumatic experiences. Evaluators and GV staff carefully prioritized gathering participants' consent with regard to the attendance of the project team during the PST, frequently checking in with participants individually, during group exercises, and via anonymous qualitative feedback gathered from survey data. There were no instances in which participants asked for the project team not to participate with them in the PST.
During the 2017-2019 evaluation period, GV hosted four PST sessions, one each in February, April, September, and October of 2018. Each cohort of PST participants completed a pretraining focus group and survey, a post training focus group and survey, and an interview and survey 90 days after the conclusion of training. PST trainers were asked to participate in a post training focus group or debriefing and to complete a post training survey after each PST cohort. Table 1 summarizes the sources of data gathered from participants.

Focus Groups
A total of eight focus groups were conducted with PST participants. Four focus groups (one per cohort) were conducted with PST participants (one per cohort) prior to starting the program to determine participants' baseline knowledge of peer support and their expectations for the training. Four focus groups (one per cohort) were conducted with PST participants immediately after training (one per cohort) to elicit their thoughts and reflections on the overall PST as well as the perceived usefulness, facilitators and barriers to understanding, and influence of the training. A post training focus group was also conducted with PST trainers to elicit their reactions to and reflections on the program.
Focus groups were either led or co-led by members of the project team, one of whom served as focus group moderator while another team member took notes. Focus groups were audio-recorded with permission, and salient themes from the focus groups were identified and grouped for analysis. 90-Day interviews. Fourteen participants spanning all four cohorts were interviewed 90 days after their PST using a semi structured, in-depth interview protocol. All participants had agreed to be contacted for a 90-day interview at the original training. Interviews were conducted via telephone and recorded with verbal permission. Salient themes were identified and grouped for analysis.

Participant observation.
Participant observation is an ethnographic research method used to gain a holistic and in-depth understanding of how individuals and communities "describe and structure their world" (Creswell, 2014, p. 207). In a traditional sense, this usually entails the researcher engaging in the lives of the research participants for a long period of time, utilizing data collection activities such as direct observation, interviewing, document analysis, reflection, analysis, and interpretation. With the development of faster approaches to qualitative inquiry, participant observation can be successfully conducted over shorter periods of time while still meeting rigorous academic research standards of thorough data collection, analysis, and reporting. Following anthropological methods, field notes were taken during participant observation, compiled, and analyzed. Evaluation team members participated in all PST activities in all four PST sessions, which allowed for reflection on the activities and modules. By participating in the PST, the project team was able to build rapport with other participants and gain additional insight through casual conversations about the PST activities.
The project team took detailed field notes during all aspects of the PST, and evaluators carefully observed group dynamics, emotions, and environmental stimuli throughout the PST and evaluation process. For instance, participants engaged in storytelling and sharing with each other throughout the PST, which sometimes put them in vulnerable positions. Both evaluators took care not to take notes at these moments, as doing so could be observed by the participants as insensitive and intrusive and likely would have resulted in a breach of trust between the researchers and the participants. In turn, this could have caused an unwelcome power imbalance in group settings. The evaluators were committed to active, participatory engagement in the PST alongside participants. When it felt inappropriate to take field notes, such as during the storytelling circles, evaluators took time to debrief with each other after the conclusion of the day's session, actively reflecting on their experiences with the group, then writing their field notes.
Surveys. The baseline surveys administered to PST participants collected data on their general demographics, history of military service, and VA service connection. Post-PST surveys asked participants to rate the PST modules and activities in terms of their usefulness and included 11 open-ended questions regarding the impact of the training, reactions to the training, and respondents' intention to use the skills they learned during training. Similarly, the post-PST surveys for trainers asked respondents to rate the PST modules and activities in terms of their usefulness and rate their perceptions of how impactful the training was for participants. The 90-day participant surveys asked participants to describe the most and least useful modules, how they had implemented PST skills in their lives since the training's end, and the same standardized measures as the baseline survey.
All surveys were administered in person in hard copy or electronically via a link to Qualtrics survey software. Responses were self-reported.

Analysis
Quantitative data (from the baseline, post, and 90-day surveys) were analyzed using Microsoft Excel and IBM SPSS. Qualitative data (from focus groups, field notes from participant observation, and 90-day interviews) were analyzed using rapid analysis to describe participant and trainer experiences; perspectives of the program for satisfaction; barriers to and facilitators of participation; and suggestions for program improvement, dissemination, and sustainability. Qualitative rapid analysis uses matrices to systematically organize and streamline data. These matrices, or compact displays, enhance the accessibility of voluminous qualitative data by condensing major findings and facilitating prompt assessment of similarities and differences within the data (Averill, 2002;Miles & Huberman, 1994). Matrices are formatted based on the purpose of the analysis; in this project, matrices were organized according to the different waves of data collection. A matrix within Microsoft Excel was used to organize data from transcripts around domains of interest established at the start of the program evaluation, and thematic analysis was conducted.
As this was a formative evaluation, evaluation team members shared their findings with GV through biweekly calls, debriefing meetings immediately after each PST session, and a written list of specific suggestions and findings delivered after each PST. This process provided GV the opportunity to implement the evaluation's recommendations for improvement as they emerged. Additionally, data-driven suggestions and strategies for improving the PST program were compiled and provided in the final report once all data were analyzed.

Findings
The PST program included a total of 38 veterans and nonveterans across four cohorts. A majority of all participants, 63%, reported veteran status, while 29% identified as civilian allies. 35% of participants identified as the spouse, partner or other family member of a veteran or active duty service member. Notably, participants could identify in more than one category (veteran, civilian ally, family/partner of veteran/service-member). The average age was 46.4, with a median age of 47 and a standard deviation of 10.3. In descending order of frequency, participants identified as White (71%), Asian (5.3%), Black or African American (5.3%), Hispanic or Latino (2.6%), Native Hawaiian or other Pacific Islander (2.6%), or Other (chose not to specify; 2.6%), with 10.5% declining to respond. The majority of participants identified as women (60.5%), with the remainder identifying as men (39.5%). All respondents identified as cisgender (i.e., their biological sex and gender identity matched). Participants tended to be married or have a partner (53%), though relationship status was unknown or not reported for 26.3% of participants. The median household size was two. Across all cohorts, all participants had at least some college or vocational school education, and a majority, 74%, had a bachelor's degree or higher. Half of the participants reported an annual household income of more than $45,000, with 21.1% reporting incomes of $35,001-$45,000, 2.6% reporting $25,001-$35,000, 7.9% reporting $15,001-$25,000, 5.3% reporting $10,001-$15,000, and 5% declining to respond.
Participants cited a number of reasons for wanting to attend the PST, including being a veteran, working with veterans, wanting to help veteran families, working with teens who have attempted suicide, wanting to serve the community, wanting to address their own personal issues, wanting to build communication skills, wanting to build/improve peer support programs or collaborate with other programs, having completed another PST program that "wasn't good, " and wanting to get more involved in GV.
Overall, participants described the PST in largely positive terms, noting that it improved their knowledge of peer support and peer support skills as well as their confidence and willingness to use these skills. As a Cohort 2 participant stated: [The PST] completely opened my mind to "peer support" as a technique for helping friends, family, coworkers, supervisees, and children work through issues for themselves rather than always be the person coming up with ideas to fix the problem and therefore take on the burden of solving the issue. It really frees up the load one carries.

Knowledge, Expectations, and Impressions
Pretraining. Participants' baseline understanding of peer support was at varying levels before the training. Some defined the term as being about listening, understanding, and/or equality or a lack of hierarchical relationships. Several participants specified that peer support is not about solving other people's problems or putting one's own problems on someone else. However, several participants related that they did not know anything about peer support when they came to the training.
PST participants expected the program to have potential impacts across their personal and professional lives. In terms of their personal lives, they expected to gain the skills they needed to "get back to being me again, " improve their emotional resiliency, improve their social skills, help break down walls, encourage a parent who is a veteran and other older veterans, fine-tune their listening skills, and avoid secondary trauma from listening. In terms of their professional lives, they expected to learn skills that would help them improve suicide prevention, "reach someone who is frozen, " assist people without getting stuck in their own heads, help homeless veterans get back on track, support student veterans, and generally better understand the people with whom they work.
Post training. In post-PST focus groups and surveys, participants talked about the PST in overall positive terms, describing it as "transformative, " "powerful stuff, " and "incredibly enlightening" and saying that they were "impressed" by the training. They also described the PST as having had a positive impact on themselves and/or the community, said that GV is "making an impact in the community" through the training, and professed that the training "actually solved a couple of really big problems for me. " Some participants described the PST in terms of skill building, stating that the PST was a "useful tool set" and "provided us with a structure we can use. " They also said that it "explained what peer support is and why it is important" and that they liked the structure of the curriculum.
When asked what surprised them most about the PST, emergent themes in focus groups and surveys centered around the camaraderie and closeness participants felt to each other and the ease and comfort they felt in sharing personal stories. Furthermore, participants were surprised not only at their own openness to sharing but also at how others have had similar experiences. Participants also noted the ability to use the skills they learned in everyday life. As one participant said, "You can apply these skills to just about any conversation. Peer support is not unique for just veterans. This is a life skill. " Finally, though some participants had attended peer support trainings before, they still described GV's PST as generating new knowledge for them. Participants stated that the new information (described as being 50% new), communication strategies, and veteran-centered nature of the program made the PST useful and that their "perception of peer support has been broadened. " One participant also said that the GV's PST "modules are the best I have received. " Participants also noted that the training format-particularly its provision of a safe space for participants to be vulnerable-improved their use of PST skills. Participants described using these new skills in a variety of areas in their lives, including at work, when volunteering, and with family and friends.

Use of PST Skills
Plans to use PST skills. Participants were very motivated to use the PST skills across their personal and professional lives. Of those who completed the post training survey, 100% of participants across all cohorts answered affirmative to the question, "Do you plan to use the PST when you return to your organization?" As one participant said, "I can use this just about anywhere, school, work, my family. I love being able to support, even if the way I do it seems small. " Several participants stated that they planned to use the skills they gained from the PST in personal ways (e.g., to be "more self-aware, " to "dial things down, " and to "check-in"), with their family (e.g., to teach the skills to their children), with their coworkers (e.g., to help teachers at their college connect with veterans), and in their communities (e.g., to address teen suicide). Several participants also planned to use the skills to create or bolster their own peer support programs, including a peer support program for veterans. A male veteran from Cohort 3 reported, "The PST helped me recognize that every interaction I have with a veteran is an opportunity to be better. We grew up in a culture [where] everyone is taking stabs at each other. " Post training use of PST skills. Surveys and 90-day interviews were conducted with PST participants (n = 14) to assess the extent to which they had used the PST skills in their communities and organizations since the conclusion of the program. These measures revealed that the PST not only influenced how participants interacted 6 Journal of Community Engagement and Scholarship, Vol. 13, Iss. 4 [2021], Art. 2 https://digitalcommons.northgeorgia.edu/jces/vol13/iss4/2 at work and with family and friends but also influenced participants' own ways of thinking.
Work. Of those interviewed 90 days post training, the majority of participants described using the skills that they gained from the PST professionally in both volunteer and paid work. They shared the PST exercises and activities with individuals and groups, including with support groups and in staff trainings. Participants also described the PST skills as improving their daily professional interactions with increased patience and an enhanced ability to build relationships. As a female nonveteran from Cohort 4 explained: I have had numerous veterans reach out to me. I am trying to get my own organization going. Oftentimes what ends up as conversations about building business ends up being a conversation about our lives. That is where I find myself using the peer support skills. As soon as the conversation switches to "well I was in Iraq…, " then that is when I find myself putting on my peer support hat.
Family and friends. The PST also affected participants' personal lives. Most of the 90-day interviewees described using PST skills with family and friends or in other informal relationships. They described improvements in communication skills, mindfulness, awareness, patience, empathy, and confidence, and some said they had used the skills to support friends in crisis. A male veteran participant from Cohort 1 said: [The PST] gave me more confidence [with] how to deal with these issues, not to be afraid to confront it; so it gave me more confidence, ' cause I was afraid if I talk to [a] veteran who has been in combat, is this going to set him off, but now I feel more confident and understand. Self. Many of the 90-day interviewees described the PST as positively impacting their ways of thinking. This included becoming more confident communicators, being more mindful, becoming more open to new relationships, experiencing feelings of empowerment, feeling an improved ability to relate to others and an improved connection to the natural world, and recognizing veterans as leaders. As one male veteran participant from Cohort 2 shared: I've been going through a lot of therapy and drug counseling over the years, but I feel like since I took that course, it's helped me open up and not be so closed off. I don't feel so nervous about talking to strangers like I used to. And I've always been extremely shy for the most part.
Peer support recipients. Interviewees used their PST training in formal and informal capacities. Peer support recipients included veterans and their families, students, clients, coworkers, fellow PST participants, parents of children with mental illness, and, generally speaking, anyone with whom PST participants interacted. One female nonveteran participant from Cohort 4 described the PST as helping her in her suicide awareness work: I talk to people that are going through a lot. I use the skills informally. And these are more parents who have children who are suicidal. But I remember the skills we learned and put them into practice about once or twice a month.
The vast majority of 90-day interviewees described using their PST skills with some frequency or regularity. For example, one female nonveteran interviewee from Cohort 4 explained that she uses the PST skills "almost daily, or at least multiple times a week where I am finding someone to use them [the PST skills] with. "

Barriers to Use of PST Skills
The evaluation revealed that cost can be a barrier for individuals seeking to enroll in the PST, and the program's cost may also impede buy-in from small organizations with tight budgets. Most participants stated in the 90-day interviews that they were self-motivated to attend the PST; only a few interviewees stated that their organization had sponsored their attendance. Interviews revealed that a major barrier to using PST seemed to be a lack of organizational sponsorship.
Once participants gained sponsorship, it seemed that organizations were on board with implementing the PST in some manner. The one participant sponsored by an organization outside of GV stated that their organization has accepted the PST, that they had not had to tailor or change any part of the PST skills/practices, that the PST was a powerful tool, and that they believed their organization could improve delivery of training to veterans and families. The three interviewees sponsored by GV stated that the PST had made a difference, that it allowed them to care for each other, and that they were using the PST in their own organizations outside of GV.
The optimal way to assess barriers to and facilitators of PST implementation at other organizations, as well as overall organizational willingness, is to interview organizational leaders to determine if their perspectives align with those of PST participants. However, during this evaluation, none of the interviewees provided evaluators with contact information for their organizational leadership. It was also not possible to evaluate the effects of receiving peer mentoring from a PST trainee, as participants did not provide contact information for those they had supported.
Long-term PST benefits. Several major themes emerged concerning long-term benefits of the PST: clarification of the definition of and skills needed for peer support, improved communication skills, increased confidence with providing peer support, and a sparked desire to help others.

Clarification of the Definition of and Skills Needed for Peer Support
Participants overwhelmingly expressed positive reactions to the PST during the 90-day interviews. Much of this favorable response stemmed from participants' improved understandings of what constituted peer support and the skills required to provide it. This included an understanding that peer support is not about "trying to fix" someone, as a female veteran participant from Cohort 1 explained, but more about being there for them: Instead of listening to [people] and thinking, "Oh I need to help this person and I need to do something for them, " now it's more of, "Well if they ask me for help or have something they want me to do, I'm willing to be there for them if it's something I am capable of doing. " Otherwise I listen, I don't take it into myself as a part of myself. Which is probably way healthier.

Improved Communication Skills
This clearer understanding of the elements necessary for peer support (e.g., empathy, boundaries, etc.) as well as what is not needed (e.g., solving other people's problems) translated into multiple other long-lasting benefits of the PST. Chief among these was improvement in professional and personal communication skills. Several participants also described learning the valuable skill of listening without judgment and "holding space" for other people, which improved their communication and ability to provide peer support. According to one female veteran participant from Cohort 1: Learning how to sit with my feelings and let people say what they need to say without me putting judgment in it or taking it personally, thinking they are judging me; and the part where-the effective listening aspect. Hold space without losing my own value.

Increased Confidence with Providing Peer Support
Several participants explained that learning and mastering these communication skills improved their confidence in their peer support ability, skills, and effectiveness. This increased confidence was facilitated by improving their understanding of how to implement peer support in a structured way. As one female veteran participant from Cohort 1 explained: [The PST] taught me what I've been seeking-it reinforced what I theorized what people needed-love, validation, structure. I felt like the training reinforced and showed me how to apply it in a more structured way instead of just winging it, which is what I had been doing.

Other Long-Term Benefits
Another long-term effect of the PST was the connection it provided to a network of like-minded people. As one participant, a male veteran from Cohort 3, stated, "[most impactful] was the network of folks I went to training with. I run into and connected with them, and that is valuable. They are all veterans. " Participants who were not veterans also described how the PST helped them better understand the struggles veterans face.

Discussion
Reintegration research has noted that a lack of social support is a key barrier to veterans' efforts to reenter civilian life (J. A. Gorman et al., 2018). Programming focused on community engagement can help ease postmilitary transitions. GV's evidence-based PST is particularly critical, given that it draws upon what the DCOE has determined are best practices and elements essential to a successful military/veteran peer support program (Money et al., 2011). Indeed, the results of this evaluation indicate that this PST provided the skills that participants needed to successfully and confidently connect with, engage, and support veterans. From better understanding their roles and goals as peer supporters, to active listening and having empathy, participants not only reported feeling more confident in their ability to communicate and connect but also expressed an increased desire to do so, ultimately increasing the community engagement opportunities available for veterans.
The content and format of the PST trainings was very personal and intimate. Group sizes were relatively small, ranging from 10 to 14 participants per workshop setting. Evaluation team members were cognizant of how their presence would affect group dynamics. Even though ethnographic research methods aim to cultivate transparency and trust between participants and researchers, power dynamics are always present and must be handled with care. As a best practice, GV staff informed all workshop participants prior to their enrollment in the program and again prior to their arrival at the workshop site that the organization was participating in a program evaluation. Before the start of each peer support workshop, the evaluation team always asked permission to attend the workshops alongside trainers and participants. This allowed the evaluation team to be active participants in the PST process as opposed to being passive participants observing and collecting data. There was never a situation in which participants did not approve of the evaluation team's participation.
Building rapport through participant observation was essential to this evaluation, as it eased any awkwardness that might have occurred in such in an intimate setting. Participant observation involved meeting with participants the night before the PST to answer any questions they might have about the evaluation, attending PST breakfasts alongside participants, and attending the PST sessions. Evaluation team members agreed that spending extra time to build rapport with participants opened the door for the establishment of trust and the free flow of information between evaluation team members, GV staff, and workshop participants.
The evaluation team also found strength in the intersectional identities of the team members. The fact that one evaluator openly identified as a woman veteran provided the researchers with an insider's perspective on the military-connected community. Her perspective was especially important when issues arose with minority service members, particularly women veterans. Her experience as a woman veteran and expertise in working with women veterans-including having written a feminist ethnography on women veterans' experiences with the transition out of military service (Downs, 2017)-provided critical insight into how women veterans reacted to the PST. For example, after this evaluator drew attention to how participants' experience of the PST might be affected by experiences of various traumas, including those perpetrated by other service members; feelings of isolation; and disconnection from "pride in service, " GV made course corrections that opened a conversation on understanding and respecting differences in military experiences. The transparent, collaborative relationship between the evaluators and GV allowed for changes to be made in real time to address input shared after the PST sessions.
GV made several other course corrections during the evaluation, including a change to the popular "council circle" activity, in which participants commonly discussed emotionally difficult or traumatic experiences. The council circle was meant to bring people together in a circle to bear witness and share with each other authentically (Growing Veterans Peer Support Training Manual, 2018). Though an experienced mental health counselor facilitated the activity, evaluators noted that it could be overwhelming for the counselor to both be attentive to participants' emotions and facilitate the workshops; upon evaluators' recommendations, GV added a cofacilitator and an emotions monitor to observe the room during activities that might elicit sensitive stories from participants.
A number of suggested modifications to the PST emerged from the collaborative process and partnership between the VHA and GV, and GV incorporated several of these suggestions into the program. Participants provided positive feedback on many modifications, including council circle and self-care and boundary modules. Participants also noted that the program helped them feel safe, allowed for vulnerability and sharing, and provided a clear understanding of peer support and required peer support skills. By being open to feedback and incorporating suggestions, GV continuously improved its PST to be more impactful and effective. The evaluators made additional recommendations in the final report, including consideration of a web-based or long-distance PST. This suggestion stemmed from the finding that cost can be a barrier to PST participation, with most participants self-funding PST participation and desiring alternative methods of enrollment. The barrier of cost was largely related to travel costs and the fact that the PST required several days of in-person participation. By offering webbased or other long-distance participation, GV could greatly improve the reach of the program.

Challenges and Limitations
So as not to overburden participants or take time away from workshops to collect survey data, attempts were made to collect pretraining surveys before the first session while participants were gathered for breakfast. The challenge with this method was that some participants showed up late, so several uncompleted surveys needed to be finished prior to the start of the PST workshop. In order to collect the survey data, GV changed the schedule to allow participants to complete the pretraining survey at the beginning of the agenda on the first day.
Other limitations may also have affected the data. For example, a potential issue inherent in focus groups is that the desire to belong and/or maintain social standing within the group may influence participants' responses. These focus groups covered several personal topics, and as part of this group dynamic participants may have felt the need to focus their responses on experiences that they might not have shared otherwise. However, the key to good focus group facilitation is the art of allowing participants to share their experiences, feelings, and perspectives while guiding the group to stay on topic. Within this evaluation, a desire to compare traumatic experiences occasionally seemed to arise, which some participants found to be detrimental to the group dynamic; this feedback was provided to GV.
The demographics of the PST participants also necessarily limit these evaluation findings. Most participants were White, women, and veterans, so their responses do not capture the broadest possible scope of perspectives. It is not clear why more diverse participants did not enroll in the PST at similar rates, but this is worth investigation. Inclusion of more diverse perspectives would help researchers better understand the potential impact of the PST program and areas where it can be improved. Evaluators did provide GV with resources to widen its outreach to diverse veteran populations.

Conclusion and Future Directions
Partnerships between the VHA and CBOs such as GV are a valuable means of expanding support for veterans. This value is evident in PST participants' descriptions of their experiences with the program. Overall, participants reported that the PST had a positive impact on their wellbeing, with implications for both their personal and professional lives. Their positive feedback demonstrated the power of the PST, and their suggestions for change make it possible to expand the program. GV's PST trainers adapted workshop content based on participant feedback immediately after the completion of the first training workshop.
A new trainer and participant manual were also produced as a result of the evaluation and participant feedback.
This partnership also exemplifies how the VHA and CBOs can improve veteran care by including veterans in program formation, implementation, and evaluation. Veterans participated in the PST itself, participated in the completion of the evaluation, and are coauthor to this article. Having a community insider on the research team provided benefits and subjective knowledge production. Having a native anthropologist (an anthropologist who is a member of the population being evaluated, in this case veterans) on the team allowed for an easier time developing rapport with program participants and facilitated a deeper understanding of certain dimensions of cultural behavior that non-native evaluators may have struggled to comprehend, especially in veterancentered evaluation and research where acronyms are often used when discussing work and service history. Given that evaluators participated in the PST as both observers and participants, rapport was developed rather quickly; this can serve as a useful model in future veteran-centered evaluation and research.
Findings from this evaluation indicate that, overwhelmingly, participants reported the GV PST to be a powerful, transformative, and positive experience. Importantly, this includes those participants who had previously attended other peer support trainings. PST participants reported implementing their peer support skills in all areas of their life, both formally and informally, and described an increased understanding of the steps and skills that peer support requires. Crucially, they noted that they do not need to "fix" anyone.
Finally, this evaluation gathered a few unintended consequences of note: • Participants reported using their peer support skills with all different populations, veterans and nonveterans; many even say that they have been able to use the peer support skills among their families to improve relationships. • Several nonveteran participants noted that a benefit of the PST was to heighten their awareness of veterans' struggles. GV will be utilizing the findings from this evaluation to further refine the PST and develop a new program (Train-the-Trainer). Future activities should include continued rigorous evaluation of the implementation of the Train-the-Trainer program and the impact of the suggested changes to both programs.