The landscape of trauma informed care in community-based HIV service organizations in the United States south

Community-based participatory research to guide adoption of culturally responsive trauma-informed HIV care throughout Nashville, Tennessee

Background

Psychological trauma is a highly prevalent driver of poor health among people with HIV (PWH) in the Southern United States (U.S.). Trauma-informed care (TIC) has potential to advance national Ending the HIV Epidemic (EHE) goals, but formative research is needed to tailor TIC implementation to complex and interdependent HIV networks. Methods: We applied a community-based participatory research (CBPR) approach to iteratively engage personnel from high volume HIV care institutions in Nashville, Tennessee. Current practices and potential implementation determinants were identified through participatory process mapping (PM) and key informant interviews. The Consolidated Framework for Implementation Research (CFIR) was applied to deductively code interview data. Personnel attending a dissemination summit developed a network-wide implementation plan.

Results

Data were collected with personnel from five institutions (e.g., community-based organizations, primary care clinics, public health department), for PM (n=48), interviews (n=35), and the summit (n=17). Results suggest there are limited trauma screenings, assessments, and services across the network. Relevant Characteristics of Individuals included a trauma-sensitive workforce committed to continuous learning and TIC adoption. Relevant Inner Setting Factors were networks and communications, with strong tension for change, high compatibility with TIC, and need for advancing cultural responsiveness. Relevant Outer Setting Factors included patient needs and resources and cosmopolitanism, with need for better leveraged mental health services. Relevant Process domains were champions and leadership, with need to diversify championship among leaders. Relevant Intervention Characteristics included relative advantage and complexity, with need for personnel wellness initiatives and increased engagement with the community as service designers. Four recommendations included development of shared communication systems, personnel wellness campaigns, routine evaluations to inform practices, and culturally responsive care initiatives.

Conclusion

Modifiable TIC determinants were identified, and a community-created implementation plan was developed to guide adoption. Future research will focus on city-wide implementation and strengthening pre-implementation research in other settings.

Process Mapping to inform implementation of Trauma-Informed Care for youth aged 14-24 with HIV in the Southern United States

Background

Trauma-Informed Care (TIC) is an evidence-based approach for improving health outcomes by providing systematic, trauma- sensitive and -responsive care. Because TIC adoption varies by setting and population, Implementation Science (IS) is particularly well-suited to guide roll-out efforts. Process Mapping (PM) is an IS model for creating shared visual depictions of systems as they are to identify rate-limiting steps of intervention adoption, but guidance on how to apply PM to guide TIC adoption is lacking. Authors of this study aimed to develop a novel method for conducting TIC-focused PM.

Methods

A real-life TIC implementation study is presented to show how TIC-focused PM was conducted in the case example of a pediatric HIV clinic in a Southern urban area with a high burden of psychological trauma among youth with HIV. A five-phase PM model was applied to evince clinic standards of care, including Preparation, planning and process identification; Data and information gathering; Map generation; Analysis; and Taking it forward. Practices and conditions from four TIC domains were assessed, including Trauma responsive services; Practices of inclusivity, safety, and wellness; Training and sustaining trauma responsiveness; and Cultural responsiveness.

Results

The TIC-focused PM method indicated the case clinic provided limited and non-systematic patient trauma screening, assessment, and interventions; limited efforts to promote professional quality of life and elicit and integrate patient experiences and preferences for care; no ongoing efforts to train and prepare workforce for trauma- sensitive or -responsive care; and no clinic-specific efforts to promote diversity, equity, and inclusion for patients and personnel.

Conclusion

Principles and constructs of resilience-focused TIC were synthesized with a five-phase PM model to generate a baseline depiction of TIC in a pediatric HIV clinic. Results will inform the implementation of TIC in the clinic. Future champions may follow the TIC-focused PM model to guide context-tailored TIC adoption.