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

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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.