COVID-19 Impact on Pain management: Highlighting, Explaining, and Realigning services (CIPHER)

背景：变性人和性别多元化(TGD)退伍军人是受伤害风险更大的优先人群 在慢性疼痛护理中断后，慢性疼痛状况以及身体和 与处方阿片类药物使用和过量风险有关的精神健康并存。此外，TGD 退伍军人由于根植于耻辱的负面经历而逃避医疗护理，报告称， 和暴力“，以及”普遍缺乏关于变性人患者和提供者护理的知识“。 意义：更高的慢性疼痛状况发生率和更高的SUD和 过量用药风险强调，持续的慢性疼痛护理和对护理计划的密切监督对于 TGD退伍军人，中断可能会产生可怕的后果。需要更好地了解和发展 改善TGD退伍军人慢性疼痛护理的战略对于支持福祉、管理和 这将有助于减轻疼痛、改善根植于提供者偏见的歧视性治疗，并防止与阿片类药物有关的危机。 创新和影响：身份发展评估和分享(想法)是一个创新的证据- 支持通过戏剧化的、拍摄的独白呈现定性数据的方法。研究 已经表明，观看一个想法的表现显著地减少了耻辱信念，而且文献表明 想法可能有助于将定性结果转化为可操作的建议，以优化未来 要小心，因为数据是以深度情景的方式呈现的-嵌入退伍军人的生活经验中。 具体目标：拟议的工作将补充退伍军人管理局资助的现有研究CIPHER，该研究的重点是 1)了解新冠肺炎后退伍军人慢性下腰痛护理的变化及其相关因素 影响；以及2)使用这些数据来制定战略，以优化未来VA疼痛服务的交付。目标1 拟议的工作将通过阐明高度优先的慢性疼痛护理经验来增强密码 人口，TGD老兵。在拟议工作的目标2中，我们将应用目标1的发现来开发一部小说， 互动干预，支持公平的TGD退伍军人护理，推进密码发展短期目标 以及优化新冠肺炎后疼痛管理服务公平提供的长期战略。 方法：在目标1中，我们将有目的地从Cipher的退伍军人队列中抽取TGD退伍军人 慢性下腰痛使用ICD-10性别认同障碍代码。我们将进行叙事性采访，以了解 关于TGD退伍军人在大流行前后的慢性疼痛护理经验。我们会 通过对面试记录的主题分析确定关键信息，特别关注未来的领域 护理优化。在《目标2》中，我们将运用创意制作一部25分钟的电影，由专业演员扮演。 来自AIM 1调查结果的关键信息。我们将与密码利益相关者和初级保健人员分享这部电影 供应商在1小时的会议期间，TGD资深小组成员参加了15分钟由PI主持的后期电影 小组讨论。利益相关者和提供商将填写一份接受前/后接受和行动问卷 -耻辱，这提供了一个综合分数，得分较低，表明制定的耻辱有所减少。一个 配对前后AAQ-S调查的差异将采用未经调整的两样本配对t检验进行评估 得分。评估想法是否可行和可接受地共享定性数据，以促进可操作 变化，我们将分配干预措施的可接受性(AIM)和干预的可行性 通过在线调查匿名测量(FIM)，该调查将包括开放式回复的空间 项目，请受访者描述想法是否/如何促进可操作的变化。我们将使用解释性的 顺序混合方法，通过定性反馈扩展定量的AIM/FIM结果。 下一步/实施：拟议的工作将产生一部描绘慢性疼痛护理的创意电影 密码利益相关者可以传播的TGD退伍军人的经验，以及前后的数据 改变提供者的污名和利益相关者对想法、可行性和可接受性的看法。

Background: Transgender and gender diverse (TGD) Veterans are a priority population at greater risk of harm following disruptions in chronic pain care, with higher rates of chronic pain conditions and of physical and mental health comorbidities associated with prescription opioid use and overdose risk. Moreover, TGD Veterans avoid medical care due to negative experiences rooted in stigma, reporting “insensitivity, harassment, and violence” and “a general lack of knowledge about transgender patients and care among providers.” Significance: Both the higher rates of chronic pain conditions and the increased prevalence of SUD and overdose risk underscore that consistent chronic pain care and close oversight of care plans are essential for TGD Veterans, and interruptions may have dire consequences. The need to better understand and develop strategies to improve chronic pain care for TGD Veterans is critical and urgent to support wellbeing, manage pain, ameliorate discriminatory treatment rooted in provider biases, and prevent opioid-related crises. Innovation and Impact: Identity Development Evaluation and Sharing (IDEAS) is an innovative, evidence- supported methodology in which qualitative data are presented via theatricalized, filmed monologues. Studies have shown that viewing an IDEAS performance significantly reduces stigma beliefs, and literature suggests IDEAS may facilitate translation of qualitative findings into actionable recommendations for optimizing future care because data are presented in deeply contextualized ways – embedded in Veterans’ life experiences. Specific Aims: The proposed work will supplement an existing VA-funded study, CIPHER, which focuses on 1) understanding changes in Veterans’ chronic low-back pain care after COVID-19 and their associated impacts; and 2) using these data to develop strategies to optimize future delivery of VA pain services. Aim 1 of the proposed work will enhance CIPHER by elucidating chronic pain care experiences of a high priority population, TGD Veterans. In aim 2 of the proposed work we will apply findings from Aim 1 to develop a novel, interactive intervention to support equitable TGD Veteran care, advancing CIPHER’s aim of developing short and long-term strategies to optimize equitable delivery of pain management services post-COVID-19. Methodology: In aim 1 we will purposefully sample TGD Veterans from CIPHER’s cohort of Veterans with chronic low back pain use ICD-10 Gender Identity Disorder codes. We will conduct narrative interviews to learn about TGD Veterans’ chronic pain care experiences prior to and following the onset of the pandemic. We will identify key messages via thematic analysis of interview transcripts, focusing especially on areas for future care optimization. In aim 2 we will apply IDEAS to produce a 25-minute film with professional actors portraying key messages from aim 1 findings. We will share the film with CIPHER stakeholders and primary care providers during a 1-hour meeting in which TGD Veteran panelists join for a 15-minute PI-moderated post-film panel conversation. Stakeholders and providers will complete a pre/post Acceptance and Action Questionnaire – Stigma, which provides a composite score with lower scores indicating reduced enacted stigma. An unadjusted two sample paired t-test will be used to assess the difference in matched pre-post AAQ-S survey scores. To assess whether IDEAS feasibly and acceptably shares qualitative data to facilitate actionable change, we will distribute the Acceptability of Intervention Measure (AIM) and the Feasibility of Intervention Measure (FIM) anonymously via an online survey that will include space for open-ended responses with each item, asking respondents to describe if/how IDEAS facilitates actionable change. We will use explanatory sequential mixed methods to expand quantitative AIM/FIM findings with qualitative feedback. Next steps/Implementation: The proposed work will result in an IDEAS film depicting chronic pain care experiences of TGD Veterans that can be disseminated by CIPHER stakeholders, as well as data on pre/post change in provider stigma and stakeholders’ perceptions of IDEAS feasibility and acceptability.