Narrative-Based Cultural Humility Training to Ensure Affirming Care for Transgender and Gender Diverse Veterans Across Services: A Pilot Feasibility Study

背景：近20%的成年变性人曾在美国军队服役。退伍军人事务部 重视并优先开展旨在培养对变性人的肯定文化和模范关怀的研究 和性别多元化(TGD)退伍军人。这项工作是至关重要的，因为TGD退伍军人有20倍于 与非TGD退伍军人相比，企图自杀和经历巨大的心理健康差距。 意义：虽然目前的退伍军人管理局研究正在检查卫生服务的利用情况以及障碍和 促进者从TGD退伍军人和退伍军人保健提供者的角度进行护理，实施 缺乏为退伍军人提供信息的、以证据为基础的文化能力培训。 创新和影响：身份发展、演进和分享(理念)是创新和有效的 为医疗保健提供者提供的减少污名培训，包括放映一部植根于TGD老兵的电影 讲述和让提供者参与后电影，主持与TGD退伍军人小组的对话。 文献表明，基于绩效的干预措施比其他干预措施更不可能引发认知阻力 培训模式，最大限度地帮助那些本来可能不会寻求这种培训的提供者。 具体目标：在目标1中，我们评估想法对退伍军人精神健康和初级保健提供者的影响， 问‘观念对服务提供商的污名观念有什么影响？’在目标2中，我们评估想法的可行性， 通过提供商、利益相关者和TGD资深人士在印第安纳州VAMC和CBOC中的可接受性和实施 反馈，询问：退伍军人初级保健和精神卫生提供者参加想法和 是否完成前/后测试？‘我们还检查了退伍军人、退伍军人和服务线经理 考虑可行和可接受的想法，并确定干预措施的特点和相关环境 随着实施的成功。我们的次要目标是探讨一项 嵌套式数据收集设计，用于评估IDEA对TGD患者的影响，方法是询问 TGD患者完成关于患者对提供商文化能力的看法的前后调查 “在匹配的岗位前调查中，有多大比例对培训过创意的供应商进行了评估？”假设：我们预计 想法将减少提供商的污名信念，达到可行性和可接受性基准，30%的 TGD患者将完成对其提供者感知的文化能力的调查。 方法：我们将为看最多TGD患者的提供者实施想法-初级保健和 心理健康-在现有的会议时间内提供最大限度的参与度。我们将衡量：1) 前/后提供者污名；2)实施成功、障碍和促进者；3)评估的可行性 TGD患者与想法培训提供者的经验。接受和行动的前后比较 问卷调查--污名调查将反映对提供者污名的影响。在这方面得分较低，经过验证 可靠的衡量标准表明，心理上有更大的灵活性，并减少了既定的耻辱。将对数据进行分析 使用适当的统计检验来考虑方差、正态分布和相关性。实施成功 将用事后构思验证的可接受性和可行性的量化措施以及 覆盖范围，并通过定性提供商、诊所负责人和TGD资深人员访谈来扩展以检查 实施障碍/促进者。评估从接受过IDEA培训的TGD患者收集数据的可行性 提供者我们将使用衡量患者看法的通用数据集项目进行TGD患者调查 供应商的文化能力，事前/事后的想法和跟踪完成率。 下一步/实施：实现这些具体目标将提高资源的可见度 为了支持TGD医疗保健，与医疗保健提供者减少污名相关的有效性数据，以及 执行和可行性数据，用于设计执行和评价未来国家 部署想法以加强对TGD退伍军人的关怀。

Background: Nearly 20% of the adult transgender population has served in the United States military. The VA values and prioritizes research that seeks to cultivate an affirming culture and exemplary care for transgender and gender diverse (TGD) Veterans. This work is critical, given that TGD Veterans are 20 times more likely to attempt suicide and experience vast mental health disparities compared with non-TGD Veterans. Significance: While current VA research is examining health services utilization as well as barriers and facilitators to care from the perspectives of TGD Veterans and VA healthcare providers, implementation of Veteran-informed, evidence-based cultural competence trainings for VA providers is lacking. Innovation and Impact: Identity Development Evolution and Sharing (IDEAS) is an innovative and effective stigma reduction training for healthcare providers that involves showing a film rooted in TGD Veteran narratives and engaging providers in a post-film, moderated conversation with a panel of TGD Veterans. Literature suggests performance-based interventions are less likely to trigger cognitive resistance than other training modalities, maximizing their ability to reach providers who may not otherwise seek out this training. Specific Aims: In Aim 1 we evaluate the impact of IDEAS on VA mental health and primary care providers, asking ‘What is the impact of IDEAS on provider stigma beliefs?’ In Aim 2 we evaluate IDEAS feasibility, acceptability, and implementation in Indiana VAMC and CBOCs via provider, stakeholder, and TGD Veteran feedback, asking: ‘What percentage of VA Primary Care and Mental Health providers attend IDEAS and complete pre/post tests?’ We also examine whether VA providers, TGD Veterans, and service line managers consider IDEAS feasible and acceptable and identify characteristics of the intervention and settings associated with implementation success. Our secondary aim is to explore the feasibility and preliminary outcomes of a nested data collection design for evaluating IDEAS’ impact on TGD patients by asking ‘What percentage of TGD patients complete pre/post surveys regarding patient perceptions of provider cultural competence’ and ‘What percentage of matched pre-post surveys evaluate IDEAS-trained providers?’ Hypotheses: We anticipate IDEAS will reduce providers’ stigma beliefs, meet feasibility and acceptability benchmarks, and that 30% of TGD patients will complete surveys about perceived cultural competence of their providers. Methodology: We will implement IDEAS for providers who see the most TGD patients – Primary Care and Mental Health – maximizing engagement by offering it during existing meeting times. We will measure: 1) pre/post provider stigma; 2) implementation success, barriers, and facilitators; and 3) feasibility of assessing TGD patient experiences with IDEAS trained providers. Pre/post comparison of Acceptance and Action Questionnaire – Stigma surveys will reflect impact on provider stigma. Lower scores on this validated and reliable measure indicate greater psychological flexibility and reduced enacted stigma. Data will be analyzed using appropriate statistical tests accounting for variance, normality, and correlation. Implementation success will be evaluated with post-IDEAS validated quantitative measures of acceptability and feasibility AS WELL AS REACH, and expanded via qualitative provider, clinic chief, and TGD veteran interviews to examine implementation barriers/facilitators. To assess feasibility of collecting data from TGD patients of IDEAS-trained providers we will conduct TGD patient surveys using common data set items that measure patient perceptions of provider cultural competence pre/post IDEAS and track completion rates. Next steps/Implementation: Accomplishing these specific aims will result in increased visibility of resources to support TGD healthcare, effectiveness data related to healthcare provider stigma reduction, and implementation and feasibility data to be used to design the implementation and evaluation of a future national deployment of IDEAS to enhance care for TGD Veterans.