key: cord-0799360-x7iis2cl
authors: Purcell, Natalie; Sells, Joanna; McGrath, Sarah; Mehlman, Haley; Bertenthal, Daniel; Seal, Karen H
title: “Then COVID happened…”: Veterans’ Health, Wellbeing, and Engagement in Whole Health Care During the COVID-19 Pandemic
date: 2021-11-03
journal: Glob Adv Health Med
DOI: 10.1177/21649561211053828
sha: 00c14e177f534ac7cf6606ef32d7cdda1dbbf6f2
doc_id: 799360
cord_uid: x7iis2cl

BACKGROUND: Little is known about the COVID-19 pandemic’s impact on US military veterans’ health, wellbeing, and care engagement. Healthcare systems like VA need additional information about the pandemic’s biopsychosocial impacts and how a Whole Health approach may help to address them. OBJECTIVE: To examine how the pandemic has affected veterans’ health, wellbeing, and engagement in the VA Whole Health System of Care. METHOD: We conducted qualitative interviews with 40 veterans at a large multicampus VA healthcare system during the pandemic. Informed by a Whole Health approach, interviews used open-ended questions to holistically explore pandemic impacts on mental and physical health, healthcare access and engagement, social support, coping strategies, and use of VA healthcare and wellness services. Interviews were conducted by telephone, audio-recorded, and analyzed using a matrix-based technique. Interviews were supplemented by an original survey assessing pandemic impacts; descriptive frequencies were calculated to describe and characterize the interviewed sample. INTERVIEW RESULTS: Nearly, all participating veterans described significant pandemic impacts on their wellbeing, especially loneliness and sorrow stemming from isolation and disruptions to ordinary routines. These emotional impacts—sometimes combined with new constraints on care access and personal mobility—disrupted veterans’ health plans and sometimes deterred engagement in both routine and wellness care. Veterans already struggling with chronic mental and physical health conditions and those who experienced transitions or losses during the pandemic described the most severe impacts on their wellbeing. Virtual VA wellness services, especially health coaching and mind-body wellness groups, were a key source of support and connection for those who engaged in them. CONCLUSION: We discuss the implications of our findings for care systems attempting to implement a Whole Health System of Care, including how they can address postpandemic barriers to engagement in healthcare and wellness programs, and how wellness programs can be leveraged to support those most at risk after the COVID-19 pandemic and in future crises.

Healthcare providers are only beginning to understand how the COVID-19 pandemic has affected population health and wellbeing, and little is known about the pandemic's impact on US military veterans specifically. What we know to date suggests potentially worrying trends for mental and emotional health, physical health and activity, and social supports, including impacts that may endure long after the pandemic is contained.

Systematic reviews examining the psychological impacts of the pandemic suggest elevated rates of stress, anxiety, and depression in the general population. [1] [2] [3] [4] Surveys conducted by the Kaiser Family Foundation and the American Psychological Association early in the pandemic found that 56% of American adults reported a negative impact on their mental health, 5 and 36% reported a "serious impact." 6 Social isolation, fear of contracting COVID-19, protective and preparatory behaviors, material and economic stressors, and disruptions to ordinary routines contributed to these mental health impacts regardless of COVID-19 infection status. 3, 4, 7 Impacts may be particularly severe for those already struggling with mental health conditions: increased stress and reduced access to established coping strategies and community supports may exacerbate symptoms and diminish quality of life. 6, 8, 9 Studies have also identified pandemic impacts on healthrelated behaviors that could negatively affect physical health and worsen chronic medical conditions. For example, home confinement, gym closures, and other safety-related precautions have been associated with reductions in healthy physical activity. 10, 11 Pandemic-related stress and isolation may also increase food consumption, food hoarding, and unhealthy eating, 10, 11 as well as alcohol and drug use. 5 Together, these behavioral changes may contribute to or exacerbate obesity and existing metabolic health conditions and may negatively impact general health in ways that could persist after the pandemic if not addressed.

At the same time, the pandemic has reduced healthcare access and engagement-for instance, through the cancellation of nonessential in-person services and the deferral of routine and preventative care. 12 Telehealth options, which generally require internet access and some comfort using associated technology, have been unevenly available and may be more difficult to access for some populations, including older people, 13, 14 the economically disadvantaged, 15 and those residing in rural areas. 3, 4 Difficulty accessing mental health services during the pandemic could prevent those with mental health conditions from receiving needed treatment and worsen psychological distress. 16 Veterans may be especially vulnerable to some of these impacts. Compared to the general population, veterans served by the VA healthcare system are older, have more physical health conditions (e.g., diabetes, 17 cancers 18 ), and also suffer disproportionately from some serious mental health conditions (e.g., posttraumatic stress). 18 Yet veterans may also benefit from a stronger social safety net than is available to the general US population, including a VA healthcare system that provides comprehensive healthcare services to over 5 million veterans. 19, 20 VA aims to deliver Whole Health 21, 22 care, which encompasses conventional medical and mental health treatment as well as proactive wellness programs, such as health education and support groups focused on building both skills and community. As a Whole Health System of Care, VA also provides access to a range of complementary and integrative health (CIH) modalities. For example, yoga, tai chi, mindfulness, and acupuncture are part of the VA health benefits package, 23 and veterans in many VA facilities also have access to group or individual Whole Health Coaching [24] [25] [26] to help them work toward their goals.

As a Whole Health System of Care, VA may be well positioned to recognize and address pandemic impacts that conventional care systems could miss, especially impacts that are subtle, emerging, or not associated with a formal medical diagnosis. This is because a Whole Health System of Care is defined as one that recognizes and responds to individual patient needs across the spectrum of biological, psychological, social, and spiritual health. The foundation of Whole

Health care is open-ended inquiry about what matters most to the patient across multiple domains of wellbeing. This inquiry, often initiated in primary care, kickstarts collaborative and ongoing Personal Health Planning 27,28 rooted in the veterans' own values and goals for their life and health. VA Personal Health Plans can encompass conventional and integrative medicine, clinical treatment and preventative wellness programming-all in service of the veteran's goals. The Whole Health System of Care is at different stages of implementation across VA, but its core components-patientdriven personal health planning and access to wellness programs and selected CIH modalities in addition to conventional care-are increasingly widespread. 21, 29 As VA-embedded researchers studying Whole Health implementation, we sought to holistically explore how veterans' lives and health have been impacted by the COVID-19 pandemic and how well the VA Whole Health System of Care is addressing their pandemic-related needs. To do so, we conducted open-ended qualitive interviews with veterans participating in a larger study of Whole Health implementation at the San Francisco VA Healthcare System (SFVAHCS). In this paper, we provide a qualitative description of their experiences during the pandemic, supplemented by quantitative survey data describing the population we interviewed and contextualizing our interview findings. We show how veterans engaged (or not) with VA care and wellness programs to help them manage pandemic-related challenges, the impact of VA's wellness programs in their lives, and how the Whole Health System of Care could be improved to better meet veterans' pandemic-related needs. Finally, we discuss the implications of our findings for care systems attempting to put Whole Health into practice and to improve their response to future healthcare crises.

The present study was conducted as a supplement to a larger implementation-effectiveness evaluation of a Whole Health intake system at SFVAHCS. The parent project evaluates a model for engaging veterans in Personal Health Planning and wellness programs. This model uses a telehealth intake visit, facilitated by a web-based Whole Health Resource Directory, to coordinate veterans' access to health coaching and wellness services. The 5-year parent project, now in its third year, includes a prospective observational study to assess the model's effectiveness in improving veterans' health, quality of life, wellness program utilization, and satisfaction; telephone survey assessments are administered at baseline, 3months, and 6-months postintake.

When the COVID-19 pandemic began, we rapidly designed and implemented the present supplemental study to monitor pandemic impacts on veterans enrolled in the parentstudy. We grounded our methods in the values and approach to inquiry that underlie the Whole Health System of Care: we used open-ended qualitative interviews to holistically assess how the pandemic affected veterans' biopsychosocial wellbeing and to inquire about engagement in VA care, with a specific focus on engagement in proactive wellness programming. We also administered a brief, original telephone survey alongside the parent-study survey assessments to assess demographic data and selected COVID-19 impacts among interviewed veterans.

Both the parent project and the present study were approved by the IRB at the University of California, San Francisco.

The study took place at the San Francisco VA Healthcare System-a large, integrated, multicampus healthcare system serving over 60 000 veterans across 7 counties in Northern California. SFVAHCS provides a full range of inpatient and outpatient services, including medical and mental health care. SFVAHCS clinicians are introduced to Whole Health as a part of their orientation, are encouraged to use a patient-centered approach to Personal Health Planning, can access formal and informal education to help them practice in accord with Whole Health values, and are informed of wellness program and integrative health referral options. Veterans have access to a wide variety of proactive wellness groups offered on an ongoing or rotating basis, including mind-body wellness groups, nutrition and mindful eating groups, and movement groups such as yoga and tai chi. Veterans can also access clinical CIH modalities, including acupuncture, chiropractic care, and integrative interdisciplinary care clinics that offer holistic, multimodal care planning (e.g., an Integrated Pain Team, an Integrative Health and Wellness Clinic). Finally, interested veterans have the option to work one-on-one with a personal Whole Health Coach to help them work toward their health goals and practice mindful awareness and self-care techniques. Notably, many wellness services were offered inperson prior to the pandemic, were temporarily suspended early in the pandemic, and were reinstated as virtual offerings within approximately 2-3 months.

The counties served by SFVAHCS were subject to California's pandemic-related restrictions and public health mandates, which were among the earliest, most restrictive, and most enduring in the United States. 30, 31 In addition, most counties served by SFVAHCS (e.g., San Francisco, San Mateo, Marin, Napa, and Sonoma) implemented restrictions beyond those mandated at the state level, including extended closures of public schools, parks, other public services, and many private businesses. 32 The region experienced two COVID-19 infection surges during the study period (one in early Spring 2020, one in early Winter 2020-2021). Statewide infection rates peaked with a 7 day average of 44 214 new daily cases reported on January 14, 2021. 33

Participants included 40 veterans, all of whom were enrolled in the parent research project at SFVAHCS. All recruited veterans had been referred by one of their VA care providers for a Whole Health intake visit to kickstart personal health planning and promote wellness program engagement. Participants met the following inclusion criteria at the time of referral per referring provider assessment: (1) the veteran expressed interest in learning about and participating in one or more wellness programs and (2) the veteran was not actively suicidal or homicidal.

Beginning early in the pandemic (April 2020) and continuing for one year (through March 2021), all active enrollees in the parent project were invited to participate in a qualitative interview concerning pandemic impacts in the 2-4 month window after their intake assessment. Veterans were invited to participate regardless of their level of engagement (or nonengagement) in VA wellness programs after their Whole Health intake. 56 were screened for interest in participating in qualitative interviews and 51 expressed interest. 40 veterans completed interviews before interviewing was suspended due to thematic saturation (a point in the iterative data collective/analysis process where interviews appear to be generating information that is consistent with existing themes and not indicative of substantially new or different themes). 34 

Interviewers conducted each interview by telephone using an original interview guide. The team's interviewers were trained in qualitative interviewing and analysis 35, 36 and have experience interviewing veterans across multiple health services research projects. 26, [37] [38] [39] [40] Whole Health values (i.e., centering what matters most to the veteran and holistic attention to the biological, psychological, social, and spiritual) and Whole Health techniques (open-ended, valuedbased inquiry touching on various domains of health and wellbeing) informed our interview questions and approach. Interviews began with broad, general inquiries about the participant's engagement in VA wellness services during the pandemic and the pandemic's impact on their health and wellbeing. Interviewers encouraged participants to highlight the impacts most important in their own lives. Subsequent probes were used to assess specific pandemic impacts across a wide range of wellbeing domains, including mood and emotions, physical activity and physical wellbeing, and wellness program access and engagement. Interviewers also asked about coping strategies, including self-care as well as healthcare system-led activities. Finally, interviewers invited participants to share their suggestions for how the VA care system, and wellness services in particular, could be improved to better meet their pandemic and postpandemic needs. See Table 1 for interview domains and sample questions. Interviews lasted 30-60 minutes. All were audiorecorded with participant permission.

Participants also completed a short, original survey assessing pandemic-related impacts. Surveys used a standard five-point Likert Scale to measure perceptions of pandemic impacts across multiple domains of health and wellbeing, including overall physical health, physical activity and exercise, mood and emotional wellbeing, and social/community support. These measures were paired with a short checklist of potential economic impacts and healthcare access impacts. Surveys also included screening questions to assess whether the participant was diagnosed with COVID-19, was hospitalized for COVID-19, or lived with anyone who was diagnosed or hospitalized. This short, simple survey was created for rapid deployment during the pandemic and was therefore not validated. The surveys were administered by telephone alongside the parent-study assessment, which included standard demographic questions. See Table 2 for assessed demographics, and Table 3 for original pandemic impact questions. For participants who completed more than one survey during the study period (due to automatic administration alongside the routine parent-study battery), we considered only the survey administered closest to the pandemic peak on January 14, 2021, with intent to capture pandemic-related impacts at their height.

Qualitative interview recordings were analyzed using a matrix-based technique developed for health services research. 36, 41 This technique was designed to be time-and resource-efficient, balancing rigor with pragmatism and yielding results that are comparable to traditional qualitative methods. [42] [43] [44] Rather than producing and analyzing transcripts, trained analysts listened to the audio-recording of each interview and prepared a written summary using a spreadsheet-based matrix organized by topical areas drawn from the interview guide. 36 Two trained analysts independently listened to and examined each audio file, summarizing participant responses for each domain and transcribing relevant quotations into the analysis matrix. The analysts then collaborated to review and compare matrices, identify and discuss recurring themes, and refine a description of each theme. Identified themes were paired with direct quotations and narrative case summaries wherever possible. Any analytic discrepancies were resolved through discussion, with audio files consulted as needed to reach consensus in the identification and description of themes. In preparing this article, we sought to represent the perspectives of a wide array of participants and, in particular, to highlight variation. 45 To protect confidentiality, nonessential identifying details have been removed or changed where these could compromise participant privacy. 46 Analysis of survey data was limited to calculation of descriptive frequencies to permit characterization of the sample and contextualization of qualitative findings.

Interview participants were relatively diverse with regard to gender (including 25% cisgender women and 6% transgender veterans) and race/ethnicity (33% from racial and ethnic minority groups). Interviewees lived across 6 counties in northern California, including a mix of urban, suburban, and rural areas. Participants skewed older in age but represented a wide variety of age groups and military service eras (26% age 18-39; 28% age 40-59; 48% age 60 or older). Nearly half (45%) had served in a combat role during their military service. Overall, participants reported a relatively high disease burden: 83% reported one or more chronic physical health conditions and 63% reported two or more. The most commonly reported physical health conditions were arthritis (53%), chronic pain (50%), gastrointestinal disorders (38%), and hypertension (33%). Similarly, 83% reported one or more chronic mental health conditions and 60% reported two or more. 80% of participants had depression, 45% had posttraumatic stress, and 48% reported another (unspecified) mental health condition. Demographic data are summarized in Table 2 . The incidence of COVID-19 among participants was low: only one participant had been diagnosed with COVID-19 and that participant did not require hospitalization. Nonetheless, virtually all participants reported pandemic impacts in our survey (Table 3) . With regard to mental health, 75% of our sample reported that their mood and emotional wellbeing was worse as a result of the pandemic, with 40% reporting it "a lot worse." No participants reported that the pandemic improved their mental and emotional health. With regard to physical health, 53% reported that it was worse as a result of the pandemic, with 23% reporting it "a lot worse." Physical activity and exercise were also widely impacted, with 75% reporting reductions in physical activity, and 48% reporting that their physical activity was reduced "a lot." Only 6% (2 veterans) felt that their physical health improved as a result of the pandemic. 43% reported being unable to access needed healthcare because of the pandemic.

With regard to social services, 35% of interviewees reported being unable to access needed services (e.g., childcare, public transportation) during the pandemic, and 60% reported that their access to social support was worse, with 38% reporting it to be "a lot worse" due to the pandemic. In contrast, 11% found that their social support was a little better (8%) or a lot better (3%) as a result of the pandemic. With regard to economic impacts, a significant majority (70%) reported none, but some reported significant economic impacts, including job loss (13%), housing insecurity (5%), food insecurity (5%), and difficulty paying bills for utilities and essential services (10%).

We present qualitative interview themes by topical domain, beginning with pandemic impacts on Mood and Emotional Wellbeing, Physical Activity and Health, Whole Health Care Access, and Economic and Social Wellbeing. We then present Coping Strategies, organized into Self-Directed Activities, VA Wellness Groups, and Whole Health Coaching. Finally, we present Intersecting Pandemic Impacts to illustrate connections among themes across topical domains.

When veterans described the pandemic impacts that were most significant in their own lives, emotional and psychological impacts were paramount. Veterans shared feelings of sorrow and disappointment at the diminished richness and variety in their social activities once vibrant social worlds became narrow and circumscribed, leaving a "limiting feeling" and a sense of loss. In the words of an older veteran:

"My wife and I have been affected, maybe in a sense kind of slightly depressed, by the complete lack of other people in our lives now. We each hold on to a few friends, some of which we visit only virtually, some of which we get to walk with only once 

in a while-once in a while, for heaven's sake! That has been profound."

Veterans admitted struggling to stay positive and "keep up morale": "It's just kind of a depressing time for everyone," shared a mother with young children, "I'm not clinically depressed, but I'm disappointed that we don't have all the things we need that we usually have." Some veterans found "uncertainty" about the future to be especially taxing and exhausting. The pandemic created disorienting changes to work, school, and home routines, and some worried that these changes might become the new normal. Those who saw activities and classes canceled often felt their absence acutely. Retired veterans shared stories of lost volunteer work and missed opportunities to give back and make a meaningful contribution to the community. One veteran noted that she used to work such long hours, she would come home and just go to bed. Now she regretted not having established a social circle for support before the pandemic.

Interviews were often laced with sadness about the scope of human loss during the pandemic-the pervasiveness of death and awareness of mortality. These emotional and psychological impacts seemed particularly severe for veterans who were already struggling with significant mental health conditions. Some described "exacerbation" of their depression, with a variety of functional impacts. "I've literally spent days in bed," acknowledged one veteran whose depression worsened during the pandemic. He and others noted that their usual coping mechanisms and support systems-going to the gym, going to church, getting out of the house and spending time with friends, dating, attending in-person support groups-were taken away by pandemic precautions and restrictions, leaving them without clear alternatives to maintain their mental health.

For those who lived alone, had no family nearby, or recently moved, feelings of loneliness and isolation could be intense and enduring. Multiple veterans shared stories of days and even weeks with no in-person contact or meaningful interactions with others. For example, a young veteran who moved to the area shortly before the pandemic related a cascade of pandemic impacts that increased his isolation and sorrow. He lost income, went into debt to pay for school, stopped taking classes, and found it especially hard to make new friends and meet people during the pandemic. When he ventured outside, he encountered masked strangers and no social interaction: "people not being human-humane-is just a culture shock for me... people not giving you a smile or a wave or a hi." He found himself feeling depressed and choosing to stay inside his apartment for weeks at a time.

Pandemic-imposed separation was especially brutal for veterans grappling with grief and loss in isolation. Those who lost loved ones during the pandemic found themselves stripped of the support, connections, and simple routines that might have helped them heal in more ordinary times. A veteran who lost his wife to cancer during the pandemic was left living alone in the home they had shared. After his wife's death, he felt a deep need to connect with others and searched for an in-person grief counseling group, but no option was available to him during the pandemic. He described his emotional state as a "quagmire" that he is desperate to escape: "so anyone who wants to throw me a line… ok." He spoke of an ongoing struggle to stay positive while he is "still trying to get through the days." As a result of the pandemic, he had to make this effort in isolation at a time when he most needed connection with others experiencing grief and loss.

Veterans sometimes found the psychological and emotional impacts of the pandemic difficult to disentangle from other social and political factors contributing to their stress and distress. Some expressed disillusionment and loss of faith in their country-the sense that the government had failed because of how bad the pandemic became and how many people died. For others, US political and social divisions, reflected in polarized responses to the pandemic, were more stressful than the pandemic itself. As one veteran put it, "It's one thing to have your own personal issues, but then to have your country attacking itself on top of it is pretty awful." Political conflict, social division, and constant news coverage of both were parallel stressors that could dramatically exacerbate anxiety: "Thank God that 2020 is over and we're not listening to constant CNN anymore," vented one veteran.

Veterans who reported that their physical health was impacted by the pandemic emphasized reductions in exercise and physical activity, especially outside of the home. For those accustomed to working out in gyms, in pools, or with groups of friends, pandemic-related restrictions and closures disrupted routines in ways that could be difficult to overcome. As one veteran put it, "I had a routine going, and I was pretty good at it, and then when everything shut down, then I no longer had that routine. I tried to adjust but I don't know…" Another veteran explained that gym workouts had been a big part of her life: before the pandemic, she went with her friends every day; the gym provided her support system and her social life. During the pandemic, she found it much harder to work out at home by herself and struggled to find a substitute that could work for her: "You're on your own now," she reflected with disappointment.

Other veterans found that gym closures and pandemicrelated disruptions presented opportunities to engage in different types of physical activity and, specifically, to be active outdoors. For some, less time commuting and fewer social engagements meant more time to walk and hike outside and, in some cases, more motivation to do so. Noted one veteran, "It forces me to do things that are good, like get out and exercise… I probably wouldn't have done it as much" if not for the pandemic.

Early in the pandemic, veterans spoke of significant disruptions in their access to VA healthcare including cancellation of appointments for a wide range of routine and preventative healthcare, as well as wellness services. The transition to virtual appointments and the rescheduling of in-person appointments felt chaotic, with some veterans missing planned or desired care in the confusion. Coordinating new appointments over the phone did not work for everyone, and veterans complained of missed calls and unreturned voicemails, especially early in the pandemic. Reporting to a VA facility for on-site care felt daunting and intimidating to some-for reasons that spanned from long, impersonal screening lines at the entry point to fear of contracting COVID-19. Some veterans chose not to pursue care because they viewed healthcare as a scarce resource during the pandemic and felt that it should be reserved for those who are "really sick."

Lack of clear, consistent information sharing perpetuated this confusion. Early in the pandemic, some veterans voiced a total lack of awareness as to what services were available, asking questions like, "What is at the VA right now? Is anybody able to go there?" These problems abated as the pandemic wore on and many services became available through telehealth or virtual visits. But, even then, veterans found themselves confused about or overwhelmed by the options available to them.

The disruptions and confusion that affected healthcare access in general also affected veterans' access to VA wellness programs and integrative health services, especially in the 2-3 month gap between the cancellation of in-person wellness groups and the creation of virtual substitutes. And, even after virtual wellness services were widely available, they did not meet everyone's needs. Telehealth technologies posed logistical and technical challenges for some despite VA's coordinated provision of free internet-connected iPads to those in need. "It's been very difficult to either hear or connect," lamented one veteran, "it sounded like she [the provider] was either underwater or talking from very far away." Wellness group visits-for example, yoga and tai chi classes-could be hard to navigate: "We started off with VVC [VA Video Connect]," observed a veteran enrolled in a nutrition group, "and that was a real struggle…for some reason, it wasn't easy to do and I think we ended up cancelling." For a variety of reasons, participating in virtual wellness activities like yoga and meditation groups did not feel attractive to everyone. It lacked the social reward of in-person connection with other veterans in a VA-an important motivator for many. Some declined to participate in any virtual wellness activities and decided to simply wait for in-person groups to be available again: "Just have to be patient, I guess," asserted one holdout.

For other veterans, the transition to telehealth made accessing healthcare, including wellness services, easier: "I don't have to come into the VA every time… I'm involved in one of these programs." A veteran who learned, for the first time, to work with the technology needed for virtual care credited the pandemic with spurring this transition and improving his communication with his care team: "I've actually learned how to use MyHealtheVet [VA secure messaging] a little more, where I can do secure messaging, and it seems to work... I get a good solid answer."

Many veterans voiced desired for a clear point of contact who could guide them to the wellness resources that best fit their needs rather than providing a sometimes-dizzying array of options or pointing them toward a large directory of wellness resources. During a time that was already overwhelming, they valued simple, direct communication tailored to their personal needs.

The stories that veterans shared during their interviews reflected significant disparities in social and economic impacts. Many maintained or even increased their income during the pandemic, and many white-collar professionals were able to work from home, avoiding long commutes and easing packed schedules. Other veterans experienced job loss, work reductions, and lowered incomes that made difficult living situations even worse-for example, crowded living conditions became more crowded, and tight budgets were stretched so thin that it became difficult to buy food and other essentials.

Social service disruptions also impacted veterans in disparate ways. Those with significant health conditions and disabilities could find their lives and routines significantly disrupted. For example, a disabled veteran at high risk of COVID-19 described how his pandemic precautions made routine chores-like a visit to the grocery store-far more arduous: "What used to take 30 minutes, now takes 45." Another disabled veteran found that his only means of transportation-public transit-felt too risky and became less accessible. As a result, he did not leave the house and saw no one other than his partner during the pandemic.

Veterans with young children found that their lives and their children's lives could be significantly impacted by lack of childcare, school closures, library closures, and park and playground closures. Explained one mother:

"I think it's just hard because people don't have their resources, all the things you ordinarily rely on as your fallbacks. We used to go to the library quite a bit, and the gym where we go has a pool and day care. So not having access to that is really hard... Even the parks.... Once they took that away, I thought, gosh, there's nothing left."

Self-Directed Activities. Veterans found a variety of ways to cope with pandemic impacts, tailored their own personal values, and leveraging the resources available to them. Those who had family and friends nearby found ways to socialize and support one another in tasks made more difficult by the pandemic, from grocery shopping to childcare. Some spoke of "bubbles" allowing in-person social contact and others maintained connections to family, friends, and co-workers through telephone calls and virtual Zoom visits. Actively maintaining and nurturing these social connections during the pandemic was a foundational coping strategy. Explained one veteran:

"That's big-being able to talk to someone. There's been times when I've had an issue, and I'll pick up my phone and go for a walk and talk to my girlfriend… We exchange stories and laugh about it… That's just been really helpful."

Veterans worked hard to create and maintain healthy habits for nutrition, exercise, sleep, and work. When prepandemic routines (e.g., swimming at the community pool weekly) were no longer an option, many found creative ways to replace them (e.g., working out to YouTube exercise videos daily). Staying engaged and busy-even maintaining a regular schedule-helped to contain the disruptions in their lives and restore a sense of stability and wellbeing. Although veterans often found that the pandemic made it more difficult for them to stay physically active, many did find ways to stay active. Several described movement and exercise as crucial strategies for maintaining their mental and physical health: "If you can move, move!" exhorted one veteran. Getting outdoors and spending time in nature-whether hiking at a nearby park or gardening in one's own backyard-was routinely praised as healing and renewing.

Veterans spoke with passion about deepened engagement in a variety of hobbies and creative projects-engagement that, in some cases, was inspired by the disruption in ordinary routines during the pandemic. After playgrounds closed, a veteran with young children invested time in designing and creating a backyard play area for her children, complete with an inflatable pool and other amenities. Others planted gardens, learned to cook new foods, fixed up old cars, and took on major clean-up projects at home. One vet appropriated a clever term for his efforts to stay busy and engaged: "Doing what I refer to as Occupational Therapy, trying to keep my hands busy, I've actually developed more culinary skills, so I'm able to cook different foods or [find] a different way to cook foods, so that's been challenging but it's been a good challenge." VA Wellness Groups. VA wellness groups were a primary coping strategy for a majority of the veterans we spoke with. Veterans used these groups, especially mindfulness and meditation groups, to relieve stress and improve mood. For example, a veteran who experienced significant stress due to the pandemic, her career, and a serious medical diagnosis praised VA meditation classes for helping her cope: "I was able to balance it out so I could… have a clear head and so then my health started improving. I'm much calmer. Even my primary care [provider] , when I talked to her said, 'you sound really good.'" Another veteran who engaged in mindfulness and yoga classes credited them with helping him reduce pandemic-related stress, prioritize activities in alignment with his values, and manage his disappointment if he did not accomplish everything he intended.

Wellness groups also helped veterans to stay on track with their health goals and create healthy routines to replace those upended by the pandemic. For example, one veteran spoke passionately about his VA nutrition classes, which sparked his interest in cooking and learning more about healthy eating. He learned about fresh ingredients and simple, easy, low-fat cooking, which left him feeling more empowered to improve his health: "On the nutrition level, it gave me some awareness of what I needed to do, and it gave me some alternative options…it created more of being aware of what I was eating and to be able to change my lifestyle." He found this especially valuable during the pandemic, and ultimately felt much healthier due to his engagement.

Although most interviewed veterans engaged in wellness services and found them helpful, several chose not to engage or dropped out. Reasons for this varied, including lack of interest in virtual offerings as an alternative to in-person offerings, a sense of overwhelm at the number of options available and how to take advantage of them, mismatch between the offering available and the veteran's work or school schedule, and personal preoccupation or distraction tied to pandemic-related challenges.

Whole Health Coaching. The wellness service most cited and praised by interviewed veterans was one-on-one Whole Health Coaching. Coaching helped veterans to establish and maintain healthy routines by providing them with structure for goal setting, check-ins, and accountability. Coaching "helps me stay on track," explained one veteran, "it kind of validates that I'm going in the right direction… kind of a checkpoint… By the time I hang up... I realize I'm still afloat." Veterans affectionately described coaching as a "structure [for] accountability," a "kick in the butt," and "a fire under me."

In many cases, health coaches helped motivate veterans to engage in a variety of other wellness activities, including yoga, tai chi, mind-body groups, nutrition groups, and selfdirected activities in support of their physical and mental health. For example, a veteran who "felt better, a lot better" after coaching, noted that he started tai chi at the suggestion of his health coach. He found that tai chi, unlike other exercise programs he had tried in the past, was suited to his physical needs with its focus on stretching and slow movement. Tai chi, paired with coaching, helped him improve his mood and ability to function and gave him something to look forward to each day. Together, they helped him "get to where I can get up in the morning and I don't feel like 'it's just another day'; it's another good day." Health coaches also helped veterans learn simple techniques for stress management to improve mood and outlook-techniques like mindful awareness, breathing, guided imagery, and visualization. One veteran described how his health coach helped him to improve his mood through "grounding techniques" that enabled him to distinguish between "reality" and his anxious thoughts. His coach's motivational approach and positivity also helped him to stay optimistic-to focus on "the pros and worry about the cons later." This shift in attitude improved his mood and mental health in a substantive way: "I was a lot more depressed before we started the coaching…since the coaching I don't feel depressed… it's kind of like a roller coaster ride sometimes, however I feel better equipped with specific interventions I can use to de-escalate situations."

Another veteran who faced significant stress at the start of the pandemic, including difficulty in accessing needed medical supplies, explained how health coaching taught him to adopt a more mindful approach to his daily struggles and, in turn, to better manage his stress: "It's been a real eyeopener, it's brought up things that I never realized about myself, and how to deal with stress for instance on a daily level, or how to navigate through COVID." For him, coaching created a shift in both perspective and routine; it "changed my whole attitude, changed everything that I'm doing."

Health coaches were sometimes a central source of personal connection and social support, providing an opportunity for veterans to express themselves and to feel genuinely heard by another person during an otherwise isolating time. As one veteran explained, coaching "gives me a pathway to express my… feelings, thoughts [and] I get some feedback." His coach reminded him that he was the expert on his own health and that he does have effective strategies for staying well and managing his anxiety and depression-"reinforcing what I already know." This, in turn, is calming and reassuring for him. Other veterans found that coaching enabled them to explore meaning and purpose questions that came up for them during the pandemic, and the coaching process was helpful in facilitating personal development and spiritual growthhelping each veteran "to be better in tune with" their values.

During interviews, veterans described the social, physical, and mental health consequences of the pandemic in ways that showed their entanglement and cumulative impact in each individual's life. For example, veterans described how the emotional impacts of the pandemic, including sadness, loneliness, and distraction affected their motivation to engage in wellness activities. "I was de-motivated for the last year," acknowledged a veteran who struggled to follow through on his health goals once the pandemic began, "It may not have been the best time to start all that [wellness programming]." Like him, others decided they were not able to move forward on the health plans and goals they set up prepandemic. They had difficulty envisioning how they could transition their prepandemic plans to a radically altered landscape: "Being at home in the shelter in place," explained one veteran, "I think some of my goalsetting was not really attainable." Often, the impacts were intersecting and cumulative: veterans simultaneously struggled with lack of space, lack of their usual companions, preoccupation with pandemic worries, and lack of motivation to carry out, for example, planned exercise routines.

Notably, the veterans who spoke of the most severe and disruptive pandemic impacts were often those already struggling with significant mental and physical health conditions or disabilities, those whose economic or social marginalization limited their access to supports, and those grappling with major transitions like the death of a loved one. For example, we heard how economic hardship and its consequences (e.g., loss of viable public transportation options) compounded veterans' isolation and affected their ability to access healthcare and other social services. Often those services, including VA wellness and support groups like exercise or nutrition groups, were a source of both social support and healthy routines. Losing them could have both physical and emotional consequences for veterans and could exacerbate existing problems.

Veterans described pandemic impacts, and the coping strategies used to address them, holistically and in context. For example, we interviewed a veteran who lost loved ones during the pandemic and found her efforts to heal and connect thwarted by pandemic restrictions on social gatherings. The loss of close friends and family members during the pandemic-and the looming threat of COVID-19-brought back the existential dread she felt during her military deployment. As a transgender woman, she was also in transition during the pandemic and felt a need for connection to others going through a similar experience. Few opportunities were available, and those that were did not always feel accessible. Fear of contracting COVID-19 made her reluctant to use public transportation and made it especially difficult for her to commute to her healthcare appointments. At the same time, her prepandemic coping strategies-spending time outdoors, in the sunlight, and with others-felt unavailable to her. She found herself struggling with depression and was not caring for her body in the ways she intended. For months, she hardly left her home.

Nonetheless, she was committed to improving her wellbeing and establishing more healthy routines, and she found that "staying busy" was critical. Despite the challenges involved, she attended her appointments at VA and took advantage of services offered to her, including therapy, exercise programs, and wellness classes. For her, "having these programs and some form of normalcy has really helped." She also engaged in health coaching, which helped her stay motivated to make positive changes in her life. She described her coach as an "accountability partner" who helped her change her diet on a budget and establish a "healthy routine" for exercise: "To have that educated motivation was influential in basically getting me off my butt." In time, and with great effort, she found herself venturing out more and her selfesteem improved:

"I was starting to feel better about myself, I was having less depression episodes, I was feeling more self-worth, more motivation to kind of step outside and look into jobs and, you know, get back into a normal daily routines that I haven't experienced since COVID started. I got really accustomed to not doing anything...so just having those things to look forward to, weekly reminders to step outside of your room...was really helpful. I think it kind of got me out of a rut."

For this veteran, like many others we spoke with, the impacts of the pandemic were multifaceted and compounding; so too were the strategies and supports that illuminated a pathway through this dark and difficult period.

Grounded in Whole Health principles, 21,22 we adopted a holistic approach to inquiring about veterans' experiences during the COVID-19 pandemic: we invited them to tell us what mattered most to them and prompted them to touch on various dimensions of their health and wellbeingemotional, physical, social, and spiritual. This approach shed light on the pandemic impacts that mattered most to each individual and showed their relationship to veterans' personal values and needs. Our approach also illuminated the complex, cumulative interplay of personal, situational, and environmental factors in defining each veteran's pandemic experience. We found that coping strategies, when they succeeded, were reasonably accessible and aligned with the values and motivations of individual veterans; when they failed, one of these essential components-accessibility or alignmentwas missing.

None of the veterans we interviewed had severe COVID-19, yet virtually all reported pandemic impacts, and those impacts could themselves be severe-including upended finances, lost jobs, lack of access to transportation, and even food insecurity. Nonetheless, what veterans most frequently wanted to discuss was the emotional and psychological fallout of pandemic-related conditions, including isolation, curbing of ordinary routines, and lack of face-to-face social contact. Veterans spoke of sorrow, despair, loneliness, and grief tied to restrictions on their movement, communication, and ability to connect with loved ones. These "soft outcomes," which might not warrant a mental health diagnosis and might not be documented in a standard medical record, were nonetheless a significant factor impacting veterans' wellbeing and their motivation to engage in wellness activities-from seeking routine preventative care to maintaining personal exercise routines. This suggests that adopting a Whole Health approach to the assessment of pandemic impacts-including holistic open-ended inquiry-may be key to understanding and addressing them.

Our findings also highlight the pandemic's role in heightening health disparities. Veterans who were already struggling with significant personal and social challenges described the most serious and disruptive pandemic impacts in their lives. Consistent with literature on the pandemic's mental health impacts, 3, 4, 6, 8, 47 those with depression and anxiety told us how the pandemic exacerbated their distress and deprived them of their usual coping strategies. Those experiencing major life changes and losses found that periods of adjustment and recovery were complicated and extended. Those with chronic medical conditions and disabilities placing them at high risk for severe COVID-19 noted significant disruptions to their daily routines, their ability to move around, and their access to healthcare services. Those in socially and economically vulnerable positions (e.g., unstable housing, limited income) described how pandemic conditions amplified that instability and made it more difficult to follow through on plans to improve their circumstances. cf. 47, 48 On the other hand, veterans who were relatively healthy and financially stable reported less distressing and severe impacts and often highlighted important silver linings like the ability to work from home and spend less time commuting. Taken together, the veteran interviews illustrate how the pandemic may cause additional harm and burden for those already struggling the most-an increasingly well-documented public health and social equity concern. 15, [47] [48] [49] Our findings thus reinforce the importance of evaluating downstream disparities in pandemic impacts and targeting proactive outreach efforts toward the already vulnerable groups impacted most. This might be accomplished through systematic screening for pandemic impacts across different dimensions of health and wellbeing (e.g., using VA's Personal Health Inventory 28 ) or specific screening of and outreach to veterans who are more likely to be vulnerable based on a combination of known demographic risk and disease burden. Further research is needed to define and evaluate potential approaches to screening and outreach. However, a Whole Health System of Care that educates clinicians about the social and environmental determinants of health and systematically engages veterans in holistic, multidimensional assessment of their wellbeing may be better equipped than a traditional care system to recognize and address potential disparities.

Interviews also revealed that veterans rely on VA for much more than medical care; many look to VA as a central source of communication, support, and connection, especially with other veterans. The pandemic disrupted this support system by limiting access to VA facilities, disrupting the provision of in-person care, and removing opportunities to socialize with other veterans at VA sites. VA acted relatively swiftly to make virtual options for medical care, mental health care, and wellness programs widely available, 48 but many veterans felt that those options were not structured to create connection and interaction between veterans, especially informal or unstructured interaction. Virtual wellness program options were a source of connection and community for many of the veterans we interviewed, and they even improved care access for some. But veterans also longed for in-person options, and some even planned to hold off on participating in any wellness groups until they resumed in person. Some veterans faced technical barriers to access-barriers that may disproportionately impact those who are older and poorer. 50 Yet, among those we interviewed, the primary concern with virtual care was the lack of opportunity to connect with others, especially other veterans, in person. Building relationships through virtual groups could feel difficult or even impossible. Our findings bolster others' recommendations that care systems cultivate a range of in-person and virtual wellness offerings. 6 These should include creative opportunities for community and connection among veterans 51 -for example, recreational gatherings or collaborative volunteer opportunities. 52 The veterans we interviewed expected VA, at a minimum, to reach out and check in on them during the pandemic. Even those who had a strong support system in place felt that more direct outreach from their VA care team would have been valuable during the pandemic. Especially early in the pandemic, veterans reported significant confusion about what services were and were not available to them. This confusion pertained not only to the integrative health and wellness programs that were the primary focus of this study, but to healthcare more broadly, sometimes including basic medical and mental health care. Many, especially older veterans, said that they missed or skipped healthcare they otherwise would have sought. Some chose not to seek healthcare at all because they thought it should be reserved for those with the greatest need during the pandemic. Our findings thus indicate information and communication gaps that VA can and should proactively address in future crises.

Notably, the veterans we interviewed were all actively seeking integrative health and wellness services at VA, and virtually all were practicing or using at least one integrative health modality (most often mindfulness, yoga, or health coaching). Users of VA integrative health services are more likely to be women and are also more likely than other veterans to report chronic pain, PTSD, and depression. 53 These conditions were also reported at high rates in our sample, reflecting a greater disease burden and potentially greater vulnerability to pandemic health and wellness impacts. However, compared to the veteran population as a whole, the veterans we interviewed may also have been more engaged and motivated to use wellness services and more willing to set and work toward health goals (prerequisites for referral to the parent-study). It is notable that, despite this motivation, engagement in wellness programs and self-care activities varied widely among the veterans we interviewed and often felt challenging or even daunting. Consistent with literature on the impact of pandemic-related stress, 6 we found that their motivation to stay engaged in wellness activities waned as pandemic-related exhaustion, overwhelm, and sadness waxed.

However, veterans also offered insight into how care systems can address pandemic-related motivation gaps and other barriers affecting engagement in wellness programs. For example, they told us that less can be more in times of stress. They did not want a wide array of wellness program options to navigate themselves. They wanted simple, specific recommendations, and entry pathways. They wanted only the information that was directly relevant to them and their needs. Broad, generic information-like our local VA's online resource directory-could lose someone who was already feeling overwhelmed. Veterans also wanted access to wellness programming on their own schedule, including opportunities to access resources on-demand (e.g., prerecorded YouTube videos). Finally, veterans wanted a single point of contact who would help them connect to wellness programs and navigate the VA care system more broadly.

Whole Health Coaching 24-26 provided something akin to this point person for many veterans. Among interviewees, one-onone coaching was often crucial to sustained engagement in wellness activities during pandemic-related disruptions. It not only facilitated engagement in VA wellness programs; it also facilitated independent, self-directed wellness activities and helped veterans harness natural supports. For many veterans, these self-directed activities-like gardening, hiking, or learning to cook-were as or more important than the wellness groups offered by the healthcare system. Coaches helped veterans to develop mindful awareness of what helped them most, to consciously plan when and how to engage in these activities, and to minimize barriers to action. Coaching was also a crucial source of connection, support, and personal growth. For many, coaching was fundamental to coping and maintaining both health and hope during the pandemic. Insofar as Whole Health Coaching is also a limited, resource-intensive program, VA health systems might consider targeting it toward veterans who are especially in need in the aftermath of the pandemic.

Our qualitative study was designed to explore and describe how the COVID-19 pandemic can affect veterans' lives and wellbeing, and how VA wellness services may (or may not) help them to cope with pandemic-related challenges. Qualitative findings can provide depth, nuance, and context that lend greater insight into human experiences, and they can also be cautiously extrapolated beyond the individual experiences of those interviewed. 54 ,55 Yet such extrapolation requires adequate representation and attentiveness to context, including attention to how interviewees' experiences may not reflect the diverse experiences of the broader population and which voices may be unrepresented. Our sample of 40 interviewees was relatively large and included more women veterans (>25%), younger veterans (>25% under 40), and veterans from racial and ethnic minority groups (>30%) than the U.S. veteran population, which is largely white (>80%), male (>90%), and older in age (46% > 65 years old). 20 Yet, we spoke with only a very small number of veterans (3) (4) (5) (6) from most racial and ethnic minority groups and did not specifically probe for their unique experiences as members of a racial and ethnic minority group. Similarly, we interviewed very few transgender veterans (2) and veterans under 30 years old (1), and our methods were not specifically designed to examine how gender, age, and other demographic categories affected interviewees' pandemic experiences. To better explore the experiences of veterans from different demographic subgroups and how they differ from the experiences of veterans in demographic majority groups, it is important to use a purposive sampling approach designed to ensure robust representation from targeted groups, as well as an interview guide tailored to exploring differential impacts across groups. There is a need for further research in this area, especially in light of the potential disparities illuminated by our work and by other research on pandemic impacts. 15, [47] [48] [49] Because our study was designed for rapid deployment in response to the pandemic, we designed our original interview and survey instruments without piloting them in advance or formally assessing their validity. For the survey instrument, we used standard question structures and response options (e.g., yes/no and a five-point Likert scale) and we refined content domains and question wording through discussion among our team members, including researchers experienced in survey design. For the interview instrument, we used a semistructured approach and encouraged our team of experienced interviewers to use probes and modify question wording and order in response to participant cues.

Our findings illustrate that Whole Health is not just an add-on, not just a luxury in the VA healthcare system. For the veterans who shared their stories with us, the wellness and coaching programs that are part of VA's Whole Health System of Care were often highly valued and considered a fundamental source of support and connection during the pandemic. Paired with VA's comprehensive medical and mental health services, access to coaching and a variety of wellness programs helped veterans to maintain their physical and mental health and bolster their resilience during a long, trying period. Our findings also underscore the importance of adopting a Whole Health approach to the assessment of pandemic impacts. Open, holistic, value-based inquiry helped us to see the impacts that mattered most to veterans and also showed us how those impacts can intersect and compound to affect veterans' wellbeing. It showed us, too, how a Whole Health System of Care might be leveraged to serve the vulnerable populations most severely affected by the COVID-19 pandemic.

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The authors would like to thank the San Francisco VA Whole Health intake team and coaching team, including Thomas Mahoney, Cynthia Sharp, Hector Cereceres, Sharmayne Yusuff, Bridget Conboy, Winnie DeGuzman, Stephanie Barry, Megan Diaz, Jennifer Tighe, Linda Abadjian, Art Cendreda, Brett Garcia, Rodney Roberson, Chaka Morgan, Amy Guion, Andrea Lynn, and Erice Major.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Veterans Health Administration Health Services Research and Development's Research to Impact for Veterans program, project number IVI-19-486. The content is solely the responsibility of the authors and does not necessarily represent the positions or policies or the Department of Veterans Affairs or any other institution.

Natalie Purcell  https://orcid.org/0000-0002-0582-9235