Promoting Military Cultural Competence among Civilian Care Providers: Learning through Program Development

Military veterans and their families belong to a unique subculture. Several studies have identified the need for helping professionals to attain military cultural competence in order to practice more effectively. In order to address this need, a Midwestern state created a military culture certificate program (MCCP). The process of developing this program is described. Eighty-two participants of the MCCP completed a pretest survey assessing their knowledge, awareness, and self-confidence in working with this population. The majority of the participants had experience working with this population already, and their survey scores indicated moderate knowledge and moderate to high levels of overall self-efficacy. Pre-test scores indicated ten areas (six in knowledge and four in self-efficacy) that may deserve increased focus for programs and trainings on military culture. While the MCCP appeared to be generally effective, findings suggest that convenient adjunctive methods of obtaining information to enhance military cultural competence would also be helpful.


Introduction
Several studies have been conducted to determine the psychological impact of recent military conflicts in Afghanistan and Iraq.It is estimated that anywhere from 19%-44% of soldiers returning from Afghanistan or Iraq met criteria for a mental health diagnosis [1][2][3][4].Unfortunately, a large number of these military members encounter barriers to receiving care largely due to concerns about the labeling and stigma associated with mental health treatment-seeking [5,6].Additionally, service members might agree that civilian providers are competent professionally, but many of these providers lack an understanding of service member's military experiences, challenges, and language.This knowledge deficit is often a significant reason why military patients discontinue treatment with community-based providers after a single visit [7].
Tanielian and colleagues [8] outlined concerns about community-based providers in their recent national survey of mental health providers.They discovered that few community-based providers had an adequate level of military cultural competency and/or used evidence-based approaches to treat problems commonly seen among veterans.In fact, they found that just 13% of the mental health providers surveyed met the study's readiness criteria for both cultural competency and delivering evidence-based care.Kilpatrick and colleagues [9] had similar findings in their survey of mental health and primary care professionals.They found that most (84%) civilian providers in their survey had no direct military experience and had not received training or experience that could have informed them about military culture.Additionally, most providers appear to ignore veteran's status when working with this population, as only 44% reported they screened their patients to see if they were currently or previously connected to the military.
Numerous people serve military and veteran populations in a wide variety of professional capacities.Even within specific fields, the opportunities are varied.For example, Savitsky, Illingworth, and DuLaney outlined practice areas for the field of social work that included "education, child welfare, domestic violence, mental health, health care, substance abuse, and criminal justice" ( [10], p. 327).They also warned that we cannot assume that services specifically targeting the military and veteran population, such as those provided by the Department of Defense or Veteran's Affairs (VA), will be able to adequately address all of the current physical and mental health needs.In response to this concern, the VA has recently instituted a new Veterans Choice Program, allowing veterans to receive more health care from community providers.These providers are thought to have greater effectiveness if they have obtained training or experience specifically related to military culture and other key issues that impact this population.
Gleeson and Hemmer [11] point out the importance of cultural competence training with physicians and other medical care providers.They outlined recommendations for medical schools; challenging them to provide military cultural competence training, involving military medical treatment facilities in training when possible, and using faculty and students in medical school who have military experience to help medical students gain the requisite military cultural competence to provide the best possible care to military members and their families.Interestingly, some scholars even consider obtaining adequate military cultural competence as a professional ethical issue.For instance, Reger, Etherage, Reger, and Gahm [12] propose that civilian psychologists are obliged to obtain these educational experiences in order to fulfill their obligation of competent practice as outlined by the APA code of ethics [13].
It is clear that veterans can benefit from professionals who have an adequate knowledge and appreciation of military culture and practice in military settings, and these providers have been called to action [14][15][16].Professionals who have learned the roles, expectations, and other knowledge about military life can better understand the basis for the thoughts, beliefs, and values of the veterans with whom they are working.This is important because credibility is highly valued in a military environment, and professionals are quickly evaluated as being either competent or incompetent.Those judged as being incompetent, regardless of how accurate this judgment may be, will likely have little chance to enact any change.
In order to address the need to increase military cultural competence, the Army National Guard of a Midwestern state followed a commonly recommended [17,18] approach for improving cultural competence by creating a multi-disciplinary, multi-institutional advisory group.This advisory group, that included the Center for Deployment Health, a state university, the Area Health Education Center program, a center for rural health, and other stakeholders, developed a military culture certificate program (MCCP) for multi-disciplinary service providers who are interested in becoming more culturally competent about the military.The majority of this group had significant experience either serving in the military, being part of a military family, or working closely with this population.The advisory group's goal was for civilian providers to be more sensitive to military issues and to possess greater military cultural competence.This group examined ways to increase the quantity of participants and had discussions about the best ways to increase the knowledge and proficiency about military culture.A member of the advisory group conducted a focus group with the state's Veteran's Advisory Council, asking council members for their input regarding the MCCP.These veterans expressed a desire to have more confidence in their provider's military cultural competence and indicated that they would be more willing to see providers if they had completed some additional training in this area.Comments from civilian providers indicated they wanted to be more confident and comfortable with providing services to veterans, service members, and their families.They felt this would increase their willingness to work with this population as well as their overall effectiveness.They also wanted to be satisfied with any training they attended.
The advisory group's ultimate goal was to provide professional development training for civilians who serve veterans and their families in order to enhance effectiveness in their service delivery.The MCCP's mission was to increase the capacity for rapport by providing professional development training to civilian providers who serve military members, veterans, and their families.The end product was an MCCP that was an 18-hour, military-specific training program.It was offered over the course of three separate, nonconsecutive days.Because trainings were offered in various locations, some participants had to wait a month or longer before the next training opportunity was available.Each training day addressed two of six core areas.These core areas included: (1) Overview of Military Culture; (2) Deployment; (3) Family Impact; (4) Military Ethics; (5) Behavioral Health Issues; and (6) Field Experience.
The MCCP target audience included: (1) licensed mental health clinicians; (2) physicians, nurses, physician assistants, and nurse practitioners; (3) clergy; (4) attorneys; and (5) others including law enforcement, emergency workers, and case managers.Prior to commencing, all MCCP participants were asked to complete a survey designed to collect demographic data and assess their self-efficacy with the veteran population.This self-efficacy measurement was guided by the literature on rapport building [19][20][21].

Methodology
The MCCP Trainings were conducted at armories located across the state largely by an Army National Guard psychologist with the assistance of the MCCP advisory group and other military members.Advertising was done primarily via word of mouth and mass emails to interested agencies and individuals.The MCCP trainings were conducted over the course of three years, ending in late 2015.Those who completed the program were given certificates that were endorsed by the Army National Guard and signed by the Adjutant General.

Participants
The sample for this study included 82 individuals who participated in the MCCP, 17 of whom completed the entire program and the post-test.Post-tests were collected from every completer upon the conclusion of their program, and these post-tests were required before being granted a certificate of completion.Given the small number of program completers, this study will speak only briefly about this group and maintain its focus on what can be learned from the individuals who completed the pre-test.
As seen in Table 1, there was a wide range of professions represented in the sample.The "other" category was almost exclusively made up of people working with veterans in some capacity (veteran service officers, vocational rehabilitation, supportive services for veteran's families, etc.).They did not fall into a "standard" profession but had a keen interest in learning more about military culture largely due to their extensive work with veterans in their current positions.The age ranges of the participants were varied and spread out fairly evenly.Everyone who participated was at least 25 years old, and four participants were over the age of 65.Over 70% of the participants were women, but this is to be expected as women predominantly represent many of the helping professions.Interestingly, 84% of participants indicated they had experience working directly with veterans and/or their family members, and 60% indicated that they work with veterans often or extensively.

Survey Instrument
Although a number of measures exist within the body of the multicultural counseling competence literature, such as the Multicultural Counseling Awareness Scale [22], they were not used for this study because they are not military-specific.Measures addressing military cultural competence are only now just emerging but were not available when the MCCP was being developed.For example, Meyer, Hall-Clark, Hamaoka, and Peterson [23] recently developed a measure focusing on the skills, attitudes, and knowledge desired for military cultural competence and tested it among students entering medical school.The MCCP measure followed a highly regarded format that Sue and colleagues [24] developed in which they identified three dimensions of multicultural competency; attitudes/beliefs, knowledge, and skills.After conducting a literature review on multicultural competence with an emphasis on military cultural competence and rapport building, the MCCP advisory group decided to develop an MCCP assessment scale that adopted a similar framework.Additionally, the advisory group decided that the MCCP should focus on improving rapport building and should measure program participants' self-efficacy about their skill with the military and veteran population.Therefore, a portion of the MCCP assessment scale adopted a framework outlined by Bandura [25].Bandura's framework for standard self-efficacy scales proposes that participants rate their efficacy beliefs, or confidence, on a 100-point scale ranging in 10 unit intervals.Items were phrased in the terms "can do" rather than "will do" to help ensure content validity.Items were also pre-tested among advisory group members and interested graduate students.Ambiguous items were rewritten or discarded.This final scale assessed participants' knowledge and attitudes of military culture and their sense of self-efficacy when engaging with military, veterans, and their families.At the start of the program and again upon program completion, participants were administered the MCCP assessment scale.
The MCCP assessment scale was comprised of 26 items that were used to assess participants' knowledge of military culture (e.g., I understand the rank and organizational structure of the military), as well as their level of confidence when encountering several possible scenarios (e.g., provide effective support for a veteran and their family).Nine items measured participants' military knowledge, while the remaining 17 items evaluated their sense of self-efficacy (see Table 2).

Knowledge and Awareness Subscale
1.I am well versed in the language and acronyms commonly used in the military.2. I understand the rank and organizational structure of the military.3. I fully appreciate what it is like to be deployed or have a family member deployed.4. I am well aware of the impact military life has on family members.5.I am aware of the behavioral health issues commonly found in the military.6.I understand the unique ethical issues associated with military service.7. I am very knowledgeable about the many services that are available to veterans and their families.8.I feel well educated about the political issues and the important historical aspects of recent conflicts.9. Overall I feel a strong sense of connection to the military and its members.
Confidence in Skills and Abilities Subscale 10.Working effectively with veterans.11.Show empathy toward a veteran.12. Convey an attitude of care and concern for veterans.13.Create an environment where a veteran will feel that I understand him/her.14.Establish a warm, respectful helping relationship with a veteran.15.Listen carefully to concerns of veterans and family members.16.Provide effective support for a veteran and their family.17.Assist a veteran or family member understand how I can help them meet their needs.18. Understand the special issues that veterans and their families have.For the first nine items, participants were asked to indicate their level of agreement with statements related to knowledge and awareness of military culture and to rate each based on a six-point Likert scale (1 = Strongly Disagree, 6 = Strongly Agree).They were then asked to rate their degree of perceived self-efficacy by recording a number from 0 to 100 on the 17 items outlining various professional and helping skills with veterans and their families.Finally, participants were encouraged to provide qualitative statements about their experience with the MCCP upon program completion.Specifically, they were asked to provide comments about the program, suggested changes, and/or other thoughts about this program they felt would be informative.

Psychometrics
In order to test the quality of the pre-test measure, an exploratory factor analysis was conducted on the 26 items.Results from this analysis demonstrated that the scale loaded on two factors, named Knowledge and Awareness and Confidence in Skills/Abilities with factor loadings of 0.57 to 0.94.Internal reliability was high, with Cronbach's alpha levels for both Knowledge and Awareness (α = 0.958) and Confidence in Abilities (α = 0.943).In addition, all scale items approached normality (i.e., skewness and kurtosis less than or equal to ±1.00).
The first nine items related to knowledge and awareness were summed as were the remaining 17 items related to confidence with veterans.Descriptive statistics for Knowledge and Awareness approached normality with a skewness of 0.512 and a kurtosis of 0.740 (M = 34.79,SD = 11.04).Descriptive statistics for Confidence in Skills/Abilities also approached normality with a skewness of 0.266 and a kurtosis of 0.526 (M = 1349.6,SD = 285.9).

Survey Results
Pre-tests scores suggested modest levels of military knowledge (overall mean of 3.86 out of 6) and high confidence levels (79.4 out of 100).The confidence in abilities subscale had pre-test means of 84.08 out of 100, confirming the assumption that participants who had significant experience working with veterans and their families would report high levels of confidence.
It was expected that those with high levels of experience would have higher overall scores on this test.As expected, the pre-scores were significantly higher than those with high levels of experience as compared to those with little to no experience (Knowledge and Awareness overall mean = 4.40 for extensively experienced, 3.41 for those with little/no experience; Confidence in Skills/Abilities overall mean = 88.09 for extensively experienced, 71.87 for those with little/no experience).
Individual item descriptive statistics are listed in Table 3. Internal benchmarks were developed prior to analysis [26] as a measure of military cultural competence.It was determined these benchmarks would be 4/6 or higher on the Knowledge and Awareness subscale items and 80/100 or more for the Confidence in Skills/Abilities items upon post-test.As expected, a large number of the Knowledge and Awareness subscale items did not meet benchmark on pretest (six of nine items).The means for all items in this subscale ranged from 3.39-4.34.However, 12 of the 17 items for the Confidence in Skills/Abilities subscale met the benchmark of 80 upon pre-test, suggesting a ceiling effect was in place.The means for all items in this subscale ranged from 65.3 to 88.3.Only one benchmark was not met upon post-test.This suggests that program participation may have positively impacted ten of the eleven items that did not originally meet benchmark upon pre-test and helped move them beyond benchmark upon post-test.

Discussion
Most people who attended a minimum of one training session in the area of military cultural competence had some experience working with military or veterans.This is understandable, as those who work with this population would be more apt to be interested in learning more.Overall, the participants of this program had generally high levels of perceived self-efficacy about working with this population.It can be expected that individuals who work with this population will have the strongest desire to have high levels of confidence and cultural competence.The MCCP seemed to primarily help those who already had fairly adequate levels of military cultural competence become even more competent.While this is seen as a positive outcome, the organizations that created this program hoped to reach a wider audience, especially those who had very low levels of military cultural competence.It appears that the MCCP would need to be adapted in order to successfully reach this portion of the population.Marketing would need to specifically focus on this group, trainings would need to be more convenient, and additional incentives would likely need to be offered to motivate this group to participate.
Programs such as the MCCP are generally labor-intensive and can be costly.Obtaining adequate training space, qualified trainers, successful advertising, and conducting effective program evaluation takes a great deal of time and resources.Fortunately, the actual monetary cost of this MCCP was minimal, as the trainers were either volunteers or provided training as part of their Army National Guard (ANG) duty.The ANG sponsored the majority of this program by providing space, trainers, and credibility (the certificate was signed by the Adjutant General).The MCCP advisory group were also all volunteers.Unfortunately, when the ANG changed its priorities, the program was no longer sustainable.Relying on an all-volunteer program involves risk to sustainability.Additionally, relying solely on one organization or funding source can threaten sustainability, especially if that grant or organization discontinues their support.Given the small number of completers and other operational needs, this program was only sustained for three years, concluding in 2015.Although the program may not be considered a success in terms of the sheer number of completers, it is worth noting that participants expressed very high levels of satisfaction with the portions of the program they attended and noted how useful the MCCP was for them.Post-test scores also suggest improvement in knowledge, skills, and abilities, although the low number of completers limits the validity of these findings.There is much to learn from this program about the development and maintenance of an MCCP.Those who did not complete the entire program indicated they would have preferred to attend to completion, but time constraints and work demands prohibited it.They simply did not have the time to take three days off of work to attend the entire training.This suggests that employer buy-in is an important part of programs such as this.Without employer support, participants will likely not take the time and effort required to finish.
Another factor thought to impact the low overall participation rates for the MCCP was the rural nature of the state.Some of the armory sites where training occurred were located in cities with fewer than 10,000 residents.Intensive certificate programs are likely to attract higher numbers in large population centers.The decision to provide training to these smaller communities was made as part of the program's commitment to rural veterans.While this decision appeared to impact the overall participation rates, it was conceptualized as a social justice issue.A potential way of reaching a more rural audience would be to conduct some or all of the MCCP online.This could be done in a synchronous manner through the use of online platforms such as Skype or Adobe Connect.Sessions could also be recorded and offered asynchronously, to be more convenient to attendees.
The findings and low participation also suggest that the structure of a more intensive certificate program may not be a sufficient means of promoting cultural competency by itself.Considering the high number of service providers who interact with veterans and their families, a multi-modal approach is needed to reach a broader audience.These modes may include formal training and certificate programs, classroom presentations, online trainings, and field experiences that bring the participant into more contact with military/veteran groups and their families.Fortunately, adjunctive training methods are available for professionals in order to become more culturally competent with the military.Many good resources are available on the internet from websites such as the Center for Deployment Psychology and the VA (see Appendix A).Most offer free, high-quality online trainings on military culture and other pertinent military-related topics that can cover some of the basics related to military culture.It appears that promoting these existing resources to reach a larger audience may be an effective way to provide basic-level training about military culture.Not only are they convenient, but they can also be completed in a self-paced fashion and do not require absence from work.Additionally, there are several high quality training manuals and books available that providers can read at their own pace [24,[27][28][29][30].It is important to keep in mind that all training methods have strengths and limitations, and online training may have some unique limitations that are worth considering.For instance, it can be difficult to assess the impact of these programs, and many of programs do not include an assessment as part of the training.Computer-based training can often be accomplished very quickly, with minimal effort or investment on the part of the person completing the training.Therefore, it can be difficult to assess the value of these experiences.Online methods may also lack the depth needed to help individuals understand their biases around particular cultures.There is often no opportunity to ask questions or be challenged by the instructor or other participants to better understand why the material being presented is important.
The results suggest there may be areas that deserve greater emphasis when we examine pre-test means by question.Table 3 indicates there are six areas from the Knowledge and Awareness subscale and four items from the Confidence in Abilities subscale that may deserve greater emphasis when designing programs addressing military cultural competence.Participants indicated perceived deficits in understanding acronyms and military language, rank and organizational structure, the impact of deployment, military ethical issues, knowledge about services available, and pertinent political and historical influences.Participants also indicated lower confidence levels in working effectively with and understanding the special issues pertaining to this population, motivating veterans who are reluctant to talk, and referring veterans and their families to the most effective resources.
Another consideration for promoting military cultural competence includes the level of training that should be offered.For those who already have significant experience with the military, greater depth is required for trainings to be useful.For instance, seasoned providers may have had exposure to the perspective of the active duty population or a specific service branch, but they may benefit from understanding the unique challenges faced by reservists, National Guard members or the unique perspectives from other service branches.For those who have little to no experience with the military population, trainings that focus on basic concepts are the essential first steps.It would be ideal to have a variety of training sources available so that participants from all experience levels could self-select the training that best fits their needs.Future MCCPs could strive to scaffold training, providing beginner, intermediate, and advanced training levels for participants.This could help to meet the need of more seasoned providers and encourage less-experienced providers to enhance their cultural competence by attending trainings at more advanced levels once they are comfortable with the basics.
Future research can focus on the limitations of the MCCP provided above.One of the limitations of the MCCP assessment is the lack of behavioral or other-rated measures of clinical competence.These help reduce bias and can counter potentially inflated self-efficacy ratings.Additionally, the MCCP assessment scale needs additional validation, as it lacks convergent and discriminant validity.There are several validated multicultural counseling competence measures such as one developed by Ponterotto and colleagues [22] available for comparison.New measures of military cultural competence [23] also show promise and may provide useful comparisons for further validation.Finally, future research could help us better understand how enhancing military cultural competence will impact service provision for the military and veteran population [31].
As military conflicts continue to go on across the world, it is clear that there will be a long-term need for training and training materials on this topic to be available.Creative ways to enhance already existing programs and training structures will be needed as helping professionals seek ways to be more effectively adapt their care to military culture.

19 .
Communicate unconditional acceptance for veterans and their families.20.Assist the veteran in modulating feelings about their decision-making process.21.Know how much to motivate veterans if they are reluctant to talk about something.22. Quickly develop rapport with veterans and their families.23.Effectively express care for the concerns of veterans and their families.24.Demonstrate attentive and supportive verbal communication with veterans.25.Demonstrate attentive and supportive nonverbal communication behaviors with veterans.26.Referring veterans and their families to the most effective sources of help.

Table 3 .
Survey items not meeting pre-determined benchmarks at pre-test.