Integrating program-tailored universal trauma screening into HIV care: an evidence-based participatory approach

Abstract

Trauma is prevalent among HIV-infected populations and associated with negative HIV care outcomes. While several agencies have called for integrating trauma-informed care into HIV services, uptake has been limited and effective methods have not been delineated. To develop comprehensive trauma screening strategies tailored to a large, urban HIV care center, we aimed to first understand provider and staff perceptions of the center’s current level of trauma screening and barriers and facilitators to universal screening uptake. We used a mixed-methods convergent parallel design: quantitative assessments with 31 providers and staff and in-depth interviews with 19 providers and staff. Quantitative assessments highlighted center strengths (i.e. assessing effects of trauma, explaining care plans to patients, providing opportunities for questions) and gaps (i.e. asking about head injuries, emotional safety). Qualitative interviews suggested center screening practices were highly-variable and limited, identified gaps in interdepartmental communication regarding results of trauma screening that led to repeated screenings and potential patient re-traumatization, screening barriers (i.e. limited time, competing clinical priorities) and facilitators (i.e. provider-driven, standardized, non-disruptive screening with clear cut-points and follow-up steps). This study provides tangible strategies for the center to begin integrating universal trauma screening, many of which could be adapted by other U.S. HIV clinics.

Introduction

Trauma is defined by the Substance Abuse and Mental Health Services Administration as “events or circumstances experienced by an individual as physically or emotionally harmful or life-threatening [with] lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being”. Trauma is highly prevalent among people living with HIV (PLWH) and associated with significant morbidity and mortality. A recent meta-analysis demonstrates that over half of women with HIV report experiencing intimate partner violence (IPV) and approximately two-fifths report experiencing child physical and/or sexual violence (Machtinger, Wilson, Haberer, & Weiss, 2012). Several studies have similarly demonstrated high rates of IPV and child abuse and other forms of trauma in men and transgender PLWH (Henny, Kidder, Stall, & Wolitski, 2007; Pence et al., 2007; Soto, Komaie, Neilands, & Johnson, 2013).

Histories of trauma among PLWH have been associated with poorer mental health, poorer adherence to HIV care and antiretroviral therapy, lower odds of virologic suppression, greater declines in CD4⁺ T-cells, more opportunistic infections, and higher AIDS-related mortality (Cohen et al., 2004; Hatcher, Smout, Turan, Christofides, & Stockl, 2015; Jewkes, Dunkle, Jama-Shai, & Gray, 2015; Kalokhe et al., 2012; Machtinger, Haberer, Wilson, & Weiss, 2012; Mugavero et al., 2007; Schafer et al., 2012). Additionally, trauma has been linked to greater reporting of substance abuse and sexual risk-taking (Kalokhe, et al., 2012; Machtinger, Haberer, et al., 2012; Pence, et al., 2007), thereby increasing risk of transmitting HIV to others. Thus, the high prevalence of trauma and its negative effects on HIV health outcomes and public health prevention efforts underscore the need for addressing trauma as part of HIV care provision (Brezing, Ferrara, & Freudenreich, 2015; Sales, Swartzendruber, & Phillips, 2016).

While the HIV Medicine Association (HIVMA) Primary Care Guidelines recommend IPV screening, they do not discuss methods for doing so, provide guidance on how to use the screening results, nor address the need for more comprehensive trauma screening (i.e., beyond IPV) and management (Aberg et al., 2014). This gap is likely a result of the dearth of evidence demonstrating clinical benefits of trauma-informed HIV care (Sales, et al., 2016), a lack of established trauma screening and referral protocols tailored to HIV care settings, and consideration of barriers to screening and referral reported in other primary care settings (i.e., limited provider time, competing clinical priorities, lack of provider experience and training) that are also applicable in the context of primary HIV care (Erickson, Hill, & Siegel, 2001; Sprague et al., 2012; Weinreb et al., 2010). We aimed to ultimately develop strategies for effective trauma screening and management tailored to the needs and building on the strengths of a large, urban HIV care center in the South. To do so, we sought to first understand provider and staff perceptions of the current implementation of trauma screening at the center and to identify associated barriers and facilitators to increasing uptake of new and/or improving existing screening practices.

Methods

Study setting and context

The study was conducted at an urban, Ryan White-funded HIV care center in the southern U.S. that serves over 5600 PLWH, the majority of whom are low-income, live in poverty, and are un- or under-insured. The center is staffed by 160 individuals and has onsite medical, dental, and transitional care, mental health, legal, housing, child care, pastoral services, substance abuse treatment, case management, and peer counseling.

Study design

From March 2017–January 2018 we conducted a comprehensive multi-tier needs assessment employing a mixed-methods convergent parallel design. As part of the needs assessment, quantitative assessments and in-depth interviews were conducted with HIV care providers and staff.

Participant recruitment

Purposive sampling was utilized to sample providers (defined as individuals who provide clinical HIV care) and staff to ensure adequate representation from the different clinics and services within the center. This included sampling from the different center clinics (i.e., pediatric/adolescent, women’s clinic, men’s clinic, mental health clinic), center support services (i.e., social services, palliative care) and staff and providers by role. To identify prospective participant roles prior to enrollment, a list of all clinic staff and providers with their specified roles was obtained from the center leadership. Participants were recruited by email.

Data collection

After providing informed consent, participants were given the option of completing the quantitative assessment and/or in-depth interview. The quantitative assessments were self-administered via SurveyGizmo with research assistants available to provide technical support. In-depth interviews were conducted by graduate research assistants, who were enrolled in a Masters of Public Health degree program, had prior training in qualitative interviewing and analysis, and prior experience in working with PLWH and/or trauma. Participants received $25 for completing the survey and $50 for completing the interview.

The survey was adapted from the National Center on Family Homelessness’ trauma-informed care (TIC) toolkit (Guarino, Soares, Konnath, Clervil, & Bassuk, 2009) through review of the tools by HIV researchers and providers practicing at the center, behavioral scientists, and local TIC experts. The study team integrated their suggested revisions. The survey spanned five implementation domains identified as essential for TIC delivery (“U.S. Department of Health and Human Services, Health Resources and Services Administration. Model Trauma System: Planning and Evaluation”, 2006). This manuscript solely focuses on one domain: trauma screening, assessment and treatment services. Forty-eight closed-ended items assessed center practices regarding communication, trauma screening, and the care initiation intake process. Response choices included “strongly disagree”, “disagree”, “agree”, and “strongly agree”.

In-depth interviews were conducted in person by trained study staff, in a private space at the clinic, and audio-recorded. Average interview duration was 30–60 minutes. The interview guide was adapted from the “Creating Cultures of Trauma-informed Care” (Fallot and Harris, 2009). Questions explored current center practices, capacity, weaknesses and strengths in trauma screening. Examples include, “When trauma screening (like screening for intimate partner violence) is done, how does that happen now? Is it like this across [Center] services?” “Are all patients screened? (If no, why not?)” and “Describe the current capacity at the [Center] for providing trauma-specific screening for patients”.

Data analysis

A 4-point Likert scale was applied to the survey responses. After examining the distribution of responses for each item, the average for each item was calculated. Qualitative data were transcribed verbatim and analyzed using NVivo software and thematic analyses. Three study team members independently reviewed 20% of transcripts, which they used to generate preliminary codes and code definitions using inductive and deductive methods (Hennink, Hutter, & Bailey, 2011). This process continued until code saturation was reached. Once the codebook was developed, five transcripts were selected for inter-coder agreement exercises. After independently coding five transcripts, coders met to discuss their analysis. Conflicts were resolved by consensus between the three coders. After consensus was achieved, each coder was responsible for coding approximately one-third of the remaining transcripts. The full study team met bi-weekly during coding to review themes as they evolved. Major themes, across all participants, were then consolidated into a narrative, and when indicated, analyzed separately by role.

Ethics statement

The study was approved by the institutional review boards of the center’s affiliated university and health system. All participants provided written informed consent prior to engaging in study activities.

Results

Participant characteristics

Fourteen providers and 17 staff completed surveys, and nine providers and ten staff completed in-depth interviews. Providers included physicians and advanced practice providers; staff included social workers, case managers, patient navigators, health educators, peer counselors, nurses, translators, patient access representatives, and pastoral and palliative care providers. Providers and staff from all four clinics and key center support services (i.e., social services, palliative care, education) participated.

Quantitative assessments

The results for the survey are presented in Tables 1–3. Tables 1–3 respectively highlight participant-perceived strengths and gaps in center communication, trauma screening, and the overall intake assessment process.

Table 1.

Staff and provider responses regarding open and respectful communication towards patients (n = 31).

Open and respectful communication towards patients	Number of participants Strongly disagree	Average score (0–3) Disagree	Agree	Strongly agree	Providers and staff (n=31)	Providers (n=14)	Staff (n=17)
Staff* members ask patients for their definitions of emotional safety.	1	13	5	6	1.6	1.1	2.1
Staff members ask patients what they need to feel emotionally safe at the [Treatment Center].	2	13	5	5	1.5	1.0	1.9
Staff members practice motivational interviewing techniques with consumers (e.g., open-ended questions, affirmations, and reflective listening).	0	1	19	6	2.2	2.0	2.3
The [Treatment Center] uses “people first” language rather than labels (i.e., “people who are experiencing homelessness” rather than “homeless people”).	1	7	11	6	1.9	1.2	2.3
Staff uses descriptive language rather than characterizing terms to describe patients (i.e., describing a person as “having a hard time getting her needs met” rather than “attention seeking”).	0	9	12	7	1.9	1.4	2.3
Staff consistently explains examination procedures and asks patients permission before touching them.	0	3	11	9	2.3	1.9	2.5
Staff consistently takes patients’ trauma histories into consideration when performing pelvic, genital, and/or rectal examinations.	0	3	10	9	2.3	2.0	2.5
Staff consistently explains the plan of care to patients.	0	2	16	11	2.3	2.0	2.6
Staff consistently gives patients opportunities to ask questions about their health and care.	0	1	16	11	2.4	2.1	2.6
Staff consistently addresses patients’ questions and concerns.	0	2	16	11	2.3	2.0	2.6
The [Treatment Center] uses “people first” language rather than labels (e.g., “people who are experiencing homelessness” rather than “homeless people”).	1	7	11	6	1.6	1.1	2.1
Staff uses descriptive language rather than characterizing terms to describe patients (e.g., describing a person as “having a hard time getting her needs met” rather than “attention seeking”).	0	9	12	7	1.5	1.0	1.9
Staff consistently explains examination procedures and asks patients permission before touching them.	0	3	11	9	2.2	2.0	2.3
Staff consistently takes patients’ trauma histories into consideration when performing pelvic, genital, and/or rectal examinations.	0	3	10	9	1.9	1.2	2.3
Staff consistently explains the plan of care to patients.	0	2	16	11	1.9	1.4	2.3
Staff consistently gives patients opportunities to ask questions about their health and care.	0	1	16	11	2.3	1.9	2.5
Staff consistently addresses patients’ questions and concerns.	0	2	16	11	2.3	2.0	2.5

^*The term “staff” in the quantitative assessments was defined as inclusive of both center providers and staff. Participants were provided this definition as part of the introduction to the assessment. Depth of shading indicates greater overall level of agreement with item.

Table 3.

Staff and provider responses regarding intake assessment process (n = 31)

Intake assessment process	Number of participants Strongly disagree	Average score (1–4) Disagree	Agree	Strongly agree	Providers and staff (n = 31)	Providers (n = 14)	Staff (n = 17)
There are private, confidential spaces available to conduct intake assessments.	0	1	15	12	2.4	2.1	2.6
The treatment center informs patients about why these questions are being asked.	0	1	13	10	2.4	1.9	2.6
The treatment center informs patients about what will be shared with others and why.	0	4	12	10	2.2	1.7	2.5
Throughout the initial assessment process, the treatment center staff* observes patients on how they are doing and responds appropriately (e.g., takes breaks).	0	1	13	7	2.3	2.0	2.4
The treatment center provides a translator for the assessment process if needed.	0	0	18	12	2.4	2.3	2.5
The intake results are shared with the patient’s assigned HIV care provider	1	5	13	9	2.1	1.6	2.4
The patient’s HIV care provider reviews the results of the initial intake with the patient.	1	11	6	8	1.8	1.2	2.5
Based on the intake assessment, patients are referred for specific services as necessary.	0	5	10	12	2.3	1.8	2.5
Re-assessments about trauma (i.e., violence, loss, homelessness) are done at least annually.	0	5	7	7	2.1	1.4	2.6
The treatment center seeks patient consent whenever it is necessary to speak with a new provider.	1	7	8	9	2.0	1.4	2.3
Staff collaborates with patients in setting their goals.	0	2	16	12	2.3	1.9	2.6
Patient goals are reviewed and updated regularly.	0	5	14	9	2.1	1.7	2.5
Before leaving the program, staff work with patients to develop a plan to address potential safety issues	0	8	10	6	1.9	1.3	2.4
Before leaving the program, staff work with patients to develop a plan to address future service needs related to trauma.	1	10	7	6	1.8	0.2	2.2

^*The term “staff” in the quantitative assessments was defined as inclusive of both center providers and staff. Participants were provided this definition as part of the introduction to the assessment. Depth of shading indicates greater overall level of agreement with item.

Qualitative findings

Present level of trauma screening

Qualitative interviews provided critical insight into the present level of trauma screening at the center and present gaps in screening practices.

Participants explained that screening practices are not universal, but often circumstance-triggered (i.e., in response to noting ecchymosis on physical exam). Many emphasized that trauma screening was dependent on individual provider-level practices and level of comfort rather than systems-level implementation:

I know some providers are more comfortable than others. It appears they’re more comfortable, I should say. So they’ll dig deeper to, you know, find out ‘Okay, how does it affect you if I do this?’ and, you know, they ask more follow-up questions. (Staff, Enrollment)

Universal screening for select forms of trauma (IPV and/or childhood abuse) only occurs for patients referred to mental health, case management, or in the pediatric/adolescent clinic (i.e., as part of initial individual service plans completed with a social worker).

There are discrepancies on how this information is sought/handled within each clinic. Pediatrics is much more in tune with trauma-informed care and performs a more thorough assessment of trauma/violence from a child protection perspective, but adult providers are not likely to specifically screen for these issues unless particularly triggered to do so. (Staff, Men’s Clinic)

Some discussed that trauma screening sometimes occurs in the intake department, but the results are often not conveyed to providers or social workers. This gap in communication could result in re-traumatization due to providers and staff unnecessarily repeating screening and a lower likelihood of patients disclosing trauma thereafter because of lack of perceived benefit in prior disclosures.

It’s not very effective if [the intake] health educator is hearing those things and then not going to tell the provider or the social worker afterwards, so then the patient’s gonna have to be asked those questions again or they’re not even linked to services at that point, you know, like “Oh, well, you’ll meet with a social worker and they can help you with that.” … If a patient feels maybe triggered by whatever was asked, they’re more than likely not going to bring it up again. (Staff, Enrollment)

Barriers to implementing universal trauma screening

Providers and staff spoke of high patient volumes, limited time, and competing clinical priorities as major barriers to trauma screening.

We only have half an hour to see the patient. And in that half-hour, you have to take care of their … physical health, of their HIV, of their sex life, of, uh, doing – and refill of medications, and everything else in between. So unless they volunteer, nobody would have the time to sit down and explore that. (Provider, Women’s Clinic)

Others discussed the lack of formal training in trauma screening:

And otherwise it’s sometimes hard to be … like a provider, talking about that, cause I don’t have training in talking to patients about trauma related events, and so really my best offer is to refer them to mental health services. (Provider, Women’s Clinic)

Other cited barriers to trauma screening were patient perceived provider insensitivity, lack of patient readiness to disclose during care initiation, and insufficient provider-patient rapport.

Universal trauma screening: a way forward

Providers and staff discussed strategies for enhancing trauma screening at the Center. Both raised the need for providers to be the primary individuals conducting the trauma screening for various reasons:

Um, I think that it [provider-driven screening] would be great because a patient may not feel comfortable talking to the tech, but maybe feel comfortable talking to the provider. (Staff, Nurse)

I would be extremely uncomfortable relying on that information [screening results conducted during intake] and then therefore, not asking those same questions again in my own words. (Provider, Men’s Clinic)

If you are not a skilled and trained counselor or provider, then it’s almost a disservice, you know what I mean? Like you say, ‘were you raped recently?’ then you check a box and move on. (Provider, Men’s Clinic)

Providers emphasized the need for such screening to be short and efficient, have clear cut-points and subsequent action steps, be non-disruptive of the flow of clinical history taking, to have flexibility to be administered in any order, standardized, and not distressing to the patient.

We are more likely to do it [if] it isn’t time-consuming, and it’s the same exact thing for every single patient … It’s the same whether it’s an old person, a young person – they all have – always have the same questionnaire. And when you have something that is very regimented, you don’t forget. (Provider, Women’s Clinic)

If it’s fast, if it’s something that I can remember without having to look at a piece of paper, if it’s something that I can incorporate into a diverse, diverse area of my patient assessment, like, doesn’t have it be done in a certain order of the patient assessment … and if there is an action item that directly results from the screening … and then if those action items are easy to remember. (Provider, Women’s Clinic)

Providers were conflicted about whether patients should first complete a paper form of screening to help guide the screening by the provider. While some thought it would be helpful to have this information available to them prior to seeing the patient, others saw value in conducting the screening face-to-face.

Staff voiced the need to introduce the screening to patients with a statement discussing potential discomfort associated with screening, with a discussion of the plan of what to do with the results, and taking caution to have patients not feel like they were being labeled by their trauma histories.

When you say ‘I’m gonna ask you some questions that can be a little triggering,’ … they might end up being a little bit more honest. And then afterwards … ‘If this is uncomfortable for you, I can – you know, we can talk about this, we can do some grounding activities, I can link you to [the mental health clinic].’ (Staff, Enrollment)

Lastly, a nurse expressed the need for more comprehensive trauma screening, inclusive of other trauma beyond IPV and child abuse:

It’s not so much just abuse or neglect, but they have other traumatic experiences that they have that they’re still dealing with … when he was on the 8th grade his dad shot and killed his mom right in front of him. Many of my patients have done time in prison. They have a witnessed certain acts, or, or been involved in certain acts, ah, themselves. And you know, things like that they still carry with them today. (Staff, Nurse)

Discussion

This study provides critical insight into the perspectives of HIV care providers and staff regarding barriers, facilitators, and strategies for the systematic implementation of universal trauma screening in a large, resource-strapped HIV outpatient care setting. In doing so, it not only suggests concrete, feasible, tailored strategies for adoption by the clinic but also demonstrates an effective process that could be adapted by other clinics to enhance their own systematic trauma screening.

The survey highlighted center strengths in trauma screening that are likely common to many U.S. HIV clinics, suggesting the infrastructure within which to integrate universal trauma screening may already exist in many settings. For example, assessing substance abuse, mental and physical health, all potential downstream effects and/or predictors of trauma experience, were identified as key center strengths. These strengths likely result from HIV care providers/staff receiving formal training in these assessments as part of their medical education and training (Armstrong). The same holds for other noted strengths (i.e., explaining the physical exam and clinical plan, and providing patients opportunities to ask questions), as rapport building and sensitive history taking are skills most HIV providers and staff are equipped with (Armstrong). Furthermore, screening for the effects of trauma is encouraged by Ryan White as many effects (i.e., substance abuse, poor mental health, sexually transmitted infections) are quality indicators on which clinics are evaluated (Honeycutt et al., 2017).

In contrast, providers/staff historically never received training in the use of “people first” language, the need to ask about emotional safety, and the need or methods for screening for head injuries and combat violence (particularly important for HIV-infected populations immigrating from conflict-torn regions and veterans). Addressing these missed opportunities through provider and staff training could enhance the comfort, compassion, and respect perceived by patients and thus, facilitate patient open disclosure of trauma history and also render providers more comfortable in conducting the screening. Delivery of agency-wide training familiarizing providers/staff with the multitude of forms, causes, and effects of trauma, as well as education on effective screening and referral practices would be a first step in enabling the study clinic to shift from its present provider-dependent, clinic/department-dependent screening to a more comprehensive, universal screening approach (“Substance Abuse and Mental Health Services Administration. Trauma-informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57”, 2014).

Additionally, the communication gap noted between departments resulting in redundant trauma screens and potential re-traumatization is likely common to other large and/or busy HIV clinical practices (Gordon, Deland, & Kelly, 2015). Simple systematic changes like enhanced personal or electronic communication and ensuring ease of access to documentation of trauma screening results could be easily instated. Limited time, high patient volumes, and competing clinical priorities – barriers identified in this study – are also essentially universal to the present-day U.S. healthcare system (Erickson, et al., 2001; Sprague, et al., 2012; Weinreb, et al., 2010). However, trauma screening and management should receive equal clinical priority as other assessments undertaken during clinical history taking given high prevalence of trauma and its effects on HIV outcomes (Machtinger, Cuca, Khanna, Rose, & Kimberg, 2015; Sales, et al., 2016). While universal trauma screening and referral when indicated (i.e., high PTSD score; immediate danger) may initially take time, longitudinally it may improve patient physical and mental health and reduce provider time spent on adherence counseling and treatment of comorbidities. Qualitative interviews emphasized that trauma screeners should be succinct, standardized, non-disruptive of clinic flow, and have clear cut-points and detailed subsequent action steps. They further suggested that providers should be the primary conductors of the trauma screening, but clinical staff could share in responsibilities of referring the patient to internal and external resources to improve clinic efficiency.

Important study limitations include potential selection bias in that interviews were limited to staff and providers willing to participate in the study and potential information bias in that data were based on perceptions and not direct observations. Additionally, the study was conducted at one site thus limiting the transferability of study findings to other HIV clinical settings.

In conclusion, this study provides critical evidence for the study site to begin to integrate universal, comprehensive trauma screening into HIV care, and the methods used herein could be adapted by other clinics. Next steps for the study clinic include identifying a center “trauma-informed care” change team and champion to help prioritize strategies for integrating new screening practices and enhancing referral processes.

Table 2.

Staff and Provider Responses Regarding Trauma Screening (n = 31).

	Strongly disagree	Disagree	Agree	Strongly agree	Providers and staff (n=31)	Providers (n=14)	Staff* (n=17)
Personal strengths	2	7	7	6	1.8	1.3	2.1
Cultural background	1	2	17	8	2.1	1.7	2.4
Social supports in the family and the community	0	1	18	9	2.3	2.1	2.4
Current level of danger from other people (e.g., restraining orders, history of domestic violence, threats from others)	0	3	14	4	2.0	2.2	2.3
History of physical, emotional, or sexual abuse and neglect as a child or adolescent	0	2	13	5	2.2	2.0	2.2
History of physical, emotional, or sexual abuse and neglect by an intimate partner/spouse	0	3	13	5	2.1	1.9	2.2
History of combat violence	1	5	8	5	1.9	1.1	2.3
History of experiencing other community-based violence	1	3	9	5	2.0	1.6	2.3
History of loss	0	6	8	6	2.0	1.5	2.3
History of homelessness	0	1	19	10	2.3	2.2	2.4
Trauma related to learning their HIV diagnosis	0	2	12	10	2.3	2.2	2.4
Previous head injury	0	9	8	5	1.8	1.8	2.2
Quality of relationship with child or children (i.e., caregiver/child attachment)	0	7	9	7	2.0	1.5	2.4
Children’s achievement of developmental tasks.	1	5	7	6	1.9	1.8	2.1
History of mental health issues	0	0	17	13	2.4	2.4	2.5
History of substance abuse	0	0	17	13	2.4	2.4	2.5
History of physical health issues	0	0	16	12	2.4	2.3	2.5

^*The term “staff” in the quantitative assessments was defined as inclusive of both center providers and staff. Participants were provided this definition as part of the introduction to the assessment. Depth of shading indicates greater overall level of agreement with item.