2023 HSR&D/QUERI National Conference

4119 — Rolling out PRIDE: Barriers and facilitators for sites implementing a veteran-centered LGBTQ+ health education group

Lead/Presenter: Sarah Wilson,  COIN - Durham
All Authors: Wilson SM (Center to Accelerate Discovery and Practice Transformation (ADAPT), Durham, NC; Duke University School of Medicine), Mulcahy, AC (Portland VA Health Care System) Lange, LM (Mindoula Health, Inc.) Eldridge, MR (VA Center to Accelerate Discovery and Practice Transformation, Durham) Weidenbacher, H (VA Center to Accelerate Discovery and Practice Transformation, Durham) Jackson, GL (VA Center to Accelerate Discovery and Practice Transformation, Durham; Duke University School of Medicine) Hilgeman, MH (Tuscaloosa VA Medical Center, University of Alabama - Birmingham)

The Veterans Health Administration (VHA) PRIDE in All Who Served health education group (PRIDE) was developed with human-centered design principles to improve health equity and access to care for lesbian, gay, bisexual, transgender, and queer/ questioning (LGBTQ+) military veterans. This 10-week program rapidly spread to over 30 VHA facilities in 4 years. Veterans receiving PRIDE experience improved LGBTQ+ identity-related resilience and reductions in suicide attempt likelihood. Despite PRIDE’s rapid spread across facilities, information is lacking on implementation determinants. The current study’s goal was to clarify determinants of PRIDE group adoption and sustainment.

A purposive sample of VHA staff (N = 19) with experience delivering or implementing PRIDE completed teleconference interviews January-April 2021. The interview guide was informed by Consolidated Framework for Implementation Research domains. Rapid qualitative matrix analysis was completed with methods to ensure rigor (e.g., prolonged engagement, triangulation, and investigator reflexivity).

Results indicated that key barriers to PRIDE group implementation were heavily related to the inner setting, including barriers to implementation readiness (e.g., low leadership support and engagement) and facility culture (e.g., systemic anti-LGBTQ+ discrimination and stigma). Key facilitators of PRIDE group implementation overwhelmingly fell under inner setting as well, including factors that enhanced implementation readiness (e.g., access to training, support, and LGBTQ+ visibility). There were also several key implementation process facilitators that enhanced engagement at sites, such as the PRIDE learning collaborative (“Community of Practice”) and the formal process of contracting and training for PRIDE sites.

Although aspects of the outer setting (e.g., availability of community resources) and societal influences (e.g., sociopolitical climate) were mentioned by some participants, the majority of factors impacting implementation success were at the VA facility level (e.g., leadership support, facilitator time, logistics of virtual group delivery) – and therefore may be more readily addressable through tailored implementation support. The importance of LGBTQ+ equity at the facility level indicates that implementation facilitation should ideally address institutional equity in addition to implementation logistics. These findings provide the opportunity to learn from early adopting clinicians so that existing facilitators within the intervention itself (e.g., PRIDE manual, peer support/ consultation) or broader VA network (e.g., intra-facility collaboration, subject matter experts across sites) can be optimally leveraged to further spread the practice. Combining effective interventions with attention to local implementation needs will be required before LGBTQ+ veterans in all areas will benefit from PRIDE and other health equity-focused interventions.

National policies in support of LGBTQ+ veterans have enabled implementation of innovative practices, like PRIDE in All Who Served, by setting expectations for access to affirmative care. However local settings and culture – including systems- and staff-level sources of discrimination and bias – have a considerable impact on the adoption success of health equity-focused programs like PRIDE. Combining effective interventions with attention to local implementation needs will be required before LGBTQ+ veterans in all areas will benefit from this and other health equity-focused innovations.