WoVeN, the Women Veterans Network: an Innovative Peer Support Program for Women Veterans

The number of women serving in the military has grown rapidly, currently representing about 15% of the U.S. Armed Forces. Despite rising numbers, women Veterans are at particularly high risk for loneliness and isolation given their minority status during service as well as in civilian communities where few women share their life experiences. Difficulties adapting to civilian life can include mental and physical wounds of war, compromised relationships and family functioning, and challenging employment transitions, resulting in poor social support and compromised physical/emotional health and well-being. Isolation after separation from service, poor understanding of the unique nature of military culture within civilian society, and lack of recognition for women’s service are unique predictors of poor mental and physical health outcomes for women Veterans. Interventions designed to mitigate effects of loneliness are gaining increasing attention and typically rely on incorporating social support into recipients’ lives. Although peerfacilitated social support interventions have been developed across populations with different areas of need, prior to the Women Veterans Network (WoVeN), there was no national peer support network specifically designed to meet the unique needs of women Veterans. Given the isolation and loneliness described by women Veterans, there was a substantial need for a sustainable social support network at both local and national levels that encompassed topics identified by women Veterans as central to improving quality of life using military culturally informed content developed by national experts (e.g., VA National Center for PTSD researchers) and Veteran focus groups and consultants.


INTRODUCTION
"Being a part of WoVeN means I belong. The feeling of belonging to the military was monumental to me. And now, as a Veteran, I get to feel connected again." -WoVeN Member The number of women serving in the military has grown rapidly, currently representing about 15% of the U.S. Armed Forces. 1,2 Despite rising numbers, women Veterans are at particularly high risk for loneliness and isolation given their minority status during service as well as in civilian communities where few women share their life experiences. 3,4 Difficulties adapting to civilian life can include mental and physical wounds of war, 5-7 compromised relationships and family functioning, [8][9][10] and challenging employment transitions, 5,8,9,11 resulting in poor social support 5,[12][13][14] and compromised physical/emotional health and well-being. 3,5,11,15,16 Isolation after separation from service, 3,4,17 poor understanding of the unique nature of military culture within civilian society, 15,[18][19][20] and lack of recognition for women's service 4,15,21 are unique predictors of poor mental and physical health outcomes for women Veterans.
Interventions designed to mitigate effects of loneliness are gaining increasing attention 22 and typically rely on incorporating social support into recipients' lives. Although peerfacilitated social support interventions have been developed across populations with different areas of need, [23][24][25] prior to the Women Veterans Network (WoVeN), there was no national peer support network specifically designed to meet the unique needs of women Veterans. Given the isolation and loneliness described by women Veterans, there was a substantial need for a sustainable social support network at both local and national levels that encompassed topics identified by women Veterans as central to improving quality of life using military culturally informed content developed by national experts 17,26,27 (e.g., VA National Center for PTSD researchers) and Veteran focus groups and consultants.
Project Goals. To answer this need, WoVeN was designed with the support of foundation funding as an innovative peer support network. 28 The primary aims of this program are to (1) foster connections and build relationships among women Veterans in local communities and nationwide and (2) develop a collaborative network of stakeholders, agencies, and organizations that share the goal of improving the quality of life of women Veterans (e.g., VA, Veteran service organizations, women Veteran-owned businesses, Veteran interest groups).

SETTING AND PARTICIPANTS
WoVeN welcomes all women-identifying Veterans of U.S. military service, regardless of era served, branch of service, or type of discharge. WoVeN's core component is a series of structured meetings led by vetted and trained Peer Leaders, offered locally in person and nationally via web-based meeting platforms. Since the program's inception in 2017, WoVeN has trained 298 Peer Leaders who have led 215 groups, serving 1444 women Veterans (see Fig. 1). Beyond participating in individual groups, WoVeN offers additional opportunities for women to connect with one another and with other agencies and organizations that align with WoVeN's mission. Over 3300 individuals have connected with WoVeN via an active social media presence, over 2100 individuals receive WoVeN's weekly newsletter, and our program website (www. wovenwomenvets.org; over 40,000 visits to date) provides information for women Veterans to connect with vetted resources in important domains (e.g., healthcare, mental healthcare, employment, housing, education). WoVeN staff selects resources to be included by reviewing the resource's website and any relevant literature and, in many cases, conducting interviews with agency staff to ensure that the S842 The Author(s) 2022 partnership supports the WoVeN mission and promotes the well-being of women Veterans.

PROGRAM DESCRIPTION
The development of WoVeN began with a literature review and focus groups conducted in three cities (Pittsburgh, Charlotte, and San Antonio) to understand the unique needs and challenges of women Veterans and Veterans' preferences for program structure. Themes of isolation and loneliness emerged, suggesting that the primary goal of the program should be forging connections among participants. WoVeN staff developed the core curriculum of eight, 90-min sessions led by two co-Peer Leaders. The curriculum was designed to first develop, and then strengthen, relationships among members of the closed groups. Captured in the WoVeN Peer Leader Manual, 29 meetings center around themes including Introductions, Transitions, Balance, Stress Relief, Connections, Trust, Esteem, and Reflections/Celebration. Openended discussion questions query both military-related and general life experiences, providing opportunities for participants to discover points of commonality as well as appreciate individual differences.
WoVeN Study Pilot. In August 2017, a pilot of the WoVeN program launched with a peer leader training conducted by WoVeN Directors, implementation of the WoVeN group curriculum by three pairs of women Veteran Peer Leaders in their home communities, and weekly consultation calls for implementation support and fidelity checks. Key lessons learned included the need for additional centralized support and resources (e.g., tip sheets, sharing of best practices across peer leaders, outreach materials to facilitate recruitment) and the critical need for two Peer Co-Leaders given the attrition inherent in an all-volunteer program.
WoVeN Expansion. Following the pilot, WoVeN grew exponentially (see Fig. 1) with new Peer Leaders trained by Co-Directors via national, in-person trainings across the country. Approaches to recruitment and growth included outreach by Peer Leaders at local events, social media engagement, paid Facebook ads in targeted cities, connections with partnering organizations, invited addresses at Veteran events and professional conferences, and via popular media (e.g., National Public Radio, New York Times, Oprah Magazine). High-quality, engaging promotional materials (e.g., YouTube videos, flyers, brochures) were instrumental in the recruitment process. Investment in website development and related technology solutions was critical to automate program and communications functions that became too labor intensive to manage manually (e.g., streamlined customer relationship management system, automated email distribution).
Train-the-Trainer Model of Dissemination. As the program grew, Peer Leader trainings conducted solely by Directors became unsustainable. Implementing a Train-the-Trainer model, wherein experienced Peer Leaders were trained to train new Peer Leaders allowed for more Peer Leaders to be trained   Fig. 1).
Other innovative approaches to training include a manualized Apprentice Model of Training 19 in which a new Peer Leader is trained by apprenticing with an experienced Peer Leader during an actual WoVeN group. Trainers could also organize smaller regional trainings following the same format as national trainings. To maintain fidelity across trainings, WoVeN Directors created a standardized training video tool 31 focused on aspects of the program that are more difficult to teach (e.g., leadership skills, Socratic Dialogue), allowing Trainers to focus on teaching the core curriculum. Under the expanded Train-the-Trainer model, WoVeN staff provided ongoing logistical and informational support for Trainers who, in turn, provided ongoing support to Peer Leaders as they implemented groups nationwide.
Online Delivery. Given the low base rates of women Veterans in the general population, it is not possible to populate inperson groups in every geographic location. Women in rural areas, those with extensive child/eldercare responsibilities, and those who are housebound due to disability or transportation challenges often face significant difficulties in accessing resources. 32,33 To increase access, WoVeN staff modified the core curriculum for online delivery, piloting them in October 2019. Soon thereafter, the COVID-19 global pandemic prohibited in-person groups. In March 2020, WoVeN pivoted entirely to an online format with groups conducted via a web meeting platform. During this challenging time, many women Veterans turned to WoVeN as a critical source of support. The increased need for connection and social support during the pandemic was exemplified by Peer Leaders running groups with meetings two or three times a week in some cases. Given the reduced burdens of local recruitment, securing meeting space and transportation, the numbers of women engaging in WoVeN groups increased rapidly (see Fig. 1). To date, Wo-VeN has conducted 104 online groups for 538 women. Despite the success of the online modality, 19% of the women who enrolled in WoVeN immediately before or during the pandemic preferred to be put on a waitlist for an in-person group experience.
In July 2020, the online delivery of programming extended to Peer Leader trainings and a Train-the-Trainers workshop. Online trainings offered substantial benefits including costeffectiveness, greater accessibility, and the ability to provide smaller, more frequent trainings. The approach also allowed for more vetting of and commitment building among potential Peer Leaders. Online trainings were as successful as in-person trainings with comparable retention rates of Peer Leaders trained in person (65%) and online (67%). Please see the Appendix for a visual of the WoVeN program structure.

PROGRAM EVALUATION
Women who enroll in groups are invited to voluntarily participate in the research component of the program conducted with the human subject protection oversight of the Boston University Institutional Review Board. Research consists of 20-min electronic surveys sent prior to starting a WoVeN group, following the conclusion of group, and at 1-and 3month follow-up intervals. As of December 2020, 669 women (46.33% of program participants) provided research data in this ongoing program. Table 1 provides baseline demographics (N = 669) and available program evaluation results (N = 176). In brief, 88.62% participants reported they would be "very likely" to refer another Veteran to WoVeN and 85.71% would participate in future WoVeN events. Among women who attended 5 or more meetings, 88.89% reported that they enjoyed group content "quite a bit or extremely" and 78.63% gained "quite a bit or extreme" value from their experience. Most participants (73.16%) reported that WoVeN had positively impacted two or more major life domains (e.g., social, recreational, work, family, religion, mental/physical health, and well-being). Self-reported levels of group enjoyment and value gained did not significantly differ between in-person and online group participants, supporting the feasibility and acceptability of leveraging online platforms for social support among women Veterans. These global reports of improvements in functioning provide indirect evidence that program goals are being met, but further evaluation of the impact of WoVeN using standardized measures is necessary. To date, WoVeN groups have been conducted in a number of public and private mental healthcare settings. Future research might explore how social support via this model might enhance clinical care.

DISCUSSION
New Horizons. Since the inception of WoVeN, the most commonly asked question has been, "What's next?" Women who complete WoVeN groups and want to continue in the program have several options including staying connected with cohorts locally, with the national community through social media, joining a new group, or training as a Peer Leader. To offer additional opportunities for engagement, staff developed 10 Alumni Group sessions, which are structurally similar to core group sessions and center around new themes such as Hope, Community, and Reintegration. WoVeN groups can continue forward as a cohort using these additional modules, or graduates from across the country can join a national Alumni Group and meet more women Veterans. To date, over 58 Alumni groups have been conducted for approximately 300 women.
In response to the often-heard sentiment that Veterans wish they had had this program when they separated from service to assist with the civilian transition, WoVeN piloted an expansion program to support women service members transitioning out of the Armed Forces. Called "Bridging ReIntegration from Dreams and Goals to Execution and Success" (BRIDGES), this expansion provides one-on-one mentorship and support during the challenging reintegration process culminating in a warm handoff to the larger WoVeN community. WoVeN women can apply to become Guides (16 women trained to date) for service members (Battle Buddies) and "give back" to this unique community in the way that only Veterans understand.
Limitations:. This program is not without limitations. First, in a national, community-based program such as WoVeN, it is difficult to evaluate the effectiveness of specific core components given the uncontrolled research design. Information from focus groups, monthly meetings with Peer Leaders (led by National Trainers) and with National Trainers (led by WoVeN Staff), qualitative data collected in open-ended survey questions and anecdotal reports from the field supplement our empirical data to assess effectiveness and inform future directions. Second, a volunteer workforce is a strength in many ways but also means Trainers and Peer Leaders may face significant competing demands. Third, a national footprint is a lofty goal and our waitlist of 650+ women is an ongoing challenge. There are a variety of reasons for this waitlist, each requiring different strategies to address. For example, logistical barriers can be reduced by offering additional groups at a wider variety of times to increase access. For women who are hesitant to begin a group experience, WoVeN is developing additional opportunities to best meet individual needs including educational webinars, meet and greets, and informational meetings.

Summary:
The WoVeN program provides an innovative alterative treatment approach, specifically targeting improved social support from peers, which may prove to be a valuable adjunct to healthcare and social services offered across a variety of settings. WoVeN has become a home for anyone who identifies as a woman and has served in the U.S. military. Over 3000 women have enrolled in the national program thus far, 1444 have taken their seat in a WoVeN group, 298 are trained Peer Leaders, and 26 have become WoVeN Trainers. While these numbers speak to the program's appeal and success, they do not capture the powerful feelings of connection among WoVeN members. Captured best by the words of a WoVeN member: "As a mom, in school, and as a Veteran -I don't feel like I really belong. I feel out of place as a female Veteran at many other Veteran organizations. And here, I feel I belong."

Contributors:
The authors wish to thank the thousands of women Veterans who comprise the WoVeN community for their ideas, feedback, and inspirational support of one another.
Funding The development, implementation, and expansion of WoVeN was supported by the Walmart Foundation, the Oak Foundation, and the Bob Woodruff Foundation through an NFL-BWF Salute to Service partnership "Healthy Lifestyles and Creating Community" grant.

Declarations:
Conflict of Interest: The authors declare that they do not have a conflict of interest.
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