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

Abstract

Background

Psychological trauma is a highly prevalent driver of poor health among people with HIV in the Southern United States. Trauma-informed care (TIC) has potential to advance national Ending the HIV Epidemic goals, but formative research is needed to tailor TIC implementation to complex and interdependent HIV networks.

Methods

We applied a community-based participatory research 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 and key informant interviews. The Consolidated Framework for Implementation Research 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), via process mapping (n = 48), interviews (n = 35) and a 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 should focus on city-wide implementation and strengthening pre-implementation research in other settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12954-9.

Background

Psychological trauma, or harmful effects resulting from exposure to adverse events (e.g., car accident, assault, racism) [1, 2], disproportionately affects people with HIV (PWH) compared to the general public [3–6]. The robust link between HIV and trauma represents a syndemic [5, 7], defined as two or more epidemics interacting synergistically and resulting in an increased disease burden [5, 8]. This syndemic occurs reciprocally so that exposures to trauma increase the likelihood of HIV acquisition, and living with HIV contributes to greater trauma exposures and effects [9]. Among PWH, these effects are associated with deleterious health outcomes, including disease progression, reduced medication and appointment adherence, and unsuppressed viremia [3, 4, 6, 10–12]. Associated psychiatric risks include substance use disorders, major depression, and Post-Traumatic Stress Disorder (PTSD) [3, 12]. Overall, the HIV-trauma syndemic poses major barriers to achieving the United States (U.S.) Ending the HIV Epidemic (EHE) goals [13]. Especially in the Southern U.S. [8], where HIV rates are almost double that of the nation [14], and PTSD rates among PWH are high (51%) [15], with racial and sexual minorities experiencing disproportionate disease burdens [16]. Consequently, HIV care providers are at high risk for vicarious trauma as an occupational hazard [17, 18]. Vicarious trauma can present similarly as primary trauma, negatively impacting professional quality of life [17–19] by reducing compassion satisfaction, increasing burnout [20, 21], and contributing to chronic exhaustion, reduced empathy, addictions, hypervigilance, minimization, and a sense of persecution, guilt, anger/cynicism, hopelessness, and disengagement from patients [18, 21]. At least two-thirds of HIV care providers nationally experience burnout [17, 22], which is associated with reductions in patient satisfaction and provider trust, appointment non-adherence, and re-traumatization of PWH [23–25].

Trauma-informed care (TIC) is an evidence-based approach for mitigating trauma effects throughout healthcare systems [17, 26]. In trauma-informed systems, personnel are trained and provided institutional resources to recognize and respond to trauma while resisting re-traumatization [2] by fostering the principles of: 1) Safety; 2) Trustworthiness and Transparency; 3) Peer Support; 4) Cross-Sector Collaboration and Mutuality; 5) Empowerment, Voice, and Choice; and 6) Cultural, Historical, and Gender Issues [2, 23]. Trauma-informed interventions are associated with decreased trauma effects, increased resilience, and improved HIV outcomes among PWH [15, 17, 27]. However, greater operationalization of the Sixth principle is required to render the construct actionable, and greater exploration is needed to define effective TIC implementation strategies.

The construct of cultural responsiveness has increasingly been applied to actionize Cultural, Historical, and Gender issues [2, 28, 29] and refers to how providers demonstrate sensitivity, in recognition that people of different backgrounds respond differently to trauma [2]. Specifically, less acknowledged forms of trauma may be experienced among minoritized populations relative to racism, microaggressions, and stigma but have been overlooked in trauma assessment tools and interventions [30]. Consequently, intentional efforts to staff HIV care environments with personnel who recognize these forms of trauma and are trained to sensitively respond to resist further traumatization are vital. Efforts to enhance representation among personnel to more closely mirror patients in these care environments are among interventions associated with changes in attitudes and commitment to actions/behaviors promoting cultural sensitivity and respect as part of care provision (via increased bias recognition, openness and confidence about racial issues, and increases in use of diverse health messaging) [31]. Nonetheless, few studies explore how cultural responsiveness explicitly relates to TIC [32] or potential implementation strategies for adopting TIC across HIV care networks or in Southern community-based HIV Organizations (CBOs) [33].

Community-Based Participatory Research (CBPR) [34] is a model that could be applied to facilitate TIC adoption, with an emphasis on cultural responsiveness. The CBPR model indicates that research should be conducted via community–academic partnerships to effect public health advocacy and make structural changes to eliminate health disparities. Application of the approach leads to collaborative change efforts by capacity building and equitable engagement of diverse community residents and members of organizations in all phases of policy change processes [35]. As a result, CBPR has been shown to improve health disparities and presents in alignment with TIC principles (e.g., collaboration and mutuality; empowerment, voice, and choice) [28]. However, limited literature explores how CBPR can be applied as an implementation strategy for TIC.

To begin addressing these gaps driving the HIV-trauma syndemic, we leveraged a CBPR model to conduct pre-implementation stage research to develop a data-driven plan for implementing TIC across a Southern, city-wide HIV care network.

Methods

Study setting

In January 2020, the Metropolitan Government of Nashville and Davidson County, overseen by the metropolitan mayor’s office, released the bylaws of the local EHE advisory council with the purpose of connecting people with HIV with treatment resources to eradicate HIV in Nashville [36]. Advisory members voted that culturally responsive [37], trauma-informed care was the greatest priority and most feasible to implement. A workgroup, representing five care institutions, was convened, with a researcher experienced in CBPR and TIC in HIV care settings (LB) asked to lead this effort.

The workgroup collectively developed a plan to explore perceived barriers and facilitators to city-wide adoption of culturally responsive TIC. The group sought to first purposively sample personnel from each of the city’s five highest-volume HIV care institutions, including two medical clinics, two CBO’s, and one metropolitan health department (See Supplementary file 1). The initial engagement approach was for workgroup members to contact each institution’s leadership to discuss the project and interest in a respectful, open manner. Leaders then invited workgroup members to describe the project to personnel and collaboratively recruit a sample of personnel representing a diverse range of perspectives, including leaders, direct care providers, support staff, and policymakers. Directors emailed personnel to describe the project and that participation would be voluntary and confidential. The study team then sent follow-up email invitations to personnel. Individuals agreeing to participate underwent electronic, self-administered consents for key informant interviews. This study was approved by Meharry Medical College IRB (protocol 21–05–1091) and the Metropolitan Public Health Department of Nashville/Davidson County (protocol 2,021,004) under 45 CFR 46.110 (F) Category (7).

Procedures

In this study, a multi-method approach was used to explore standard care, identify perceived implementation determinants, and develop a data-driven implementation plan, involving three phases (See Fig. 1): I) process mapping (PM), [15, 38, 39], II) key informant interviews, and III) a dissemination summit. Theoretical approaches were followed for conducting pre-implementation stage research [40] and reporting qualitative findings (i.e., Consolidated criteria for reporting qualitative research) [41].

Fig. 1.

Pre-implementation stage research phases and activities guiding co-production of culturally responsive trauma-informed care across the HIV care network in Nashville, Tennessee

For Phase I, personnel were convened separately from each of the five institutions between July 2021 and February 2022 to collaboratively construct institutional PMs, based on staff groupings suggested by leaders of institutions (authors AO, AC, JSK-K, TS, and CB). Workgroup members (LB and JS) explained the project to staff and asked them to identify current trauma screenings, assessments, and services, and policies related to cultural responsiveness. Staff were also asked about interest in TIC adoption. Groups were primarily in person, with a few held virtually during COVID-19 safety protocols, an average of four times to refine maps. Meetings were held with each institution to finalize individual maps (discussions continued until all attendees agreed on map components) and discuss forthcoming key informant interviews. Workgroup members synthesized all maps into one city map.

To prepare for Phase II, workgroup members updated a previously validated interview guide [42] to include attention to cultural responsiveness (See Supplementary file 2). Workgroup members again worked with leaders to identify a diverse sample. One-on-one interviews were then conducted virtually with personnel from each institution, between February—July 2022, by two research assistants (one female and one male, one with a Master of Public Health, and one with a bachelor’s degree), with previous training on qualitative interviewing and no previous relationships with interviewees. Interviews were recorded and transcribed verbatim. Participants received $50 gift cards as compensation.

Using a pre-existing codebook [42], that was informed by Consolidated Framework for Implementation Research (CFIR) 1.0. [43], three female study team members (one with a PhD in Social Work and two with master’s degrees, two of which having worked with one of the institutions in the past) employed a deductive thematic analysis approach informed by CFIR 1.0 [43]. Our primary themes included Process, Characteristics of individuals, Intervention, Inner setting factors and Outer setting factors. The initial codebook was then updated by two study personnel (JA and JS), from coding the first 20 interviews, to include codes related to cultural responsiveness. Coding discussions continued iteratively until 100% agreement was reached.

Finally, during Phase III, an additional group of personnel—representing all five institutions—was convened for 1.5 days for an internal dissemination summit in August, 2022. Summit goals were member checking results, interpretation of meaningfulness of findings, discussion of most appropriate ways to explain findings to community members, and the development of a plan for co-producing [44] TIC implementation. While attendees did not receive compensation for their time, they were provided meals and invited to co-author this publication. Attendees included local HIV care personnel from all five institutions (some from Phase II for member-checking) and an external facilitator. The city-wide map was presented with a summary of interview findings and quotes. Three groups of 5–6 people then were asked to make recommendations to share with the larger group. The goal was to reach consensus based on need, urgency, and feasibility. Data were captured by three key study personnel recording notes and presented back for the group to reach consensus on major themes during workgroup discussions.

Results

Phase I: process mapping

Forty-eight personnel were engaged for PM discussions including 16 (33%) administrators/leaders, 32 (67%) front-line/direct care providers/support staff, and 6 (13%) personnel with experience living with HIV. Other demographic characteristics were not collected in this phase. PM findings are in Fig. 2, showing (from left-to-right) how PWH enter the network care continuum (via diagnosis or intake) and then progress through primary medical and support services; below these standard entry-points, there are also wraparound services (first column, row three), including prevention services. Below standard services, we include where services are limited or non-existent. We also include overarching governing bodies or support entities that bring resources to the system (far right).

Fig. 2.

Process map depicting services and conditions relevant to trauma-informed across a metro-wide network of HIV care

Trauma responsive services differed by site, with one CBO and clinic providing some screenings, assessments, and services but not systematically or universally. The other CBO, clinic, and health department reportedly had no policies or procedures for routine trauma screenings and assessments and no trauma-specific interventions. No institutions provided routine behavioral health screenings or referrals as a standard component for all new patients/clients, underscoring a critical gap in addressing behavioral health in the region. None of the institutions provided routine or standard training in trauma/TIC. Additionally, none of the institutions had current policies to explicitly promote cultural responsiveness. However, one clinic had an institution-wide policy, one CBO was working to integrate antiracism efforts into strategic planning, and the health department had recently hired executive leadership to oversee an institution-wide initiative. Finally, while some institutions had personnel wellness initiatives, there was a universal need emphasized for improving personnel emotional wellness and retention.

Phase II: key informant interviews

Thirty-five personnel were interviewed, with ages ranging from 32 to 69 (median of 49; interquartile range of 36,57). Eighteen identified as Black (51%) and 17 as White (49%); 26 identified as female (74.3%) and 9 as male (25.7%). Results are outlined below by CFIR domain and associated construct. Table 1 provides example quotes for themes.

Table 1.

Personnel perceived barriers and facilitators to implementation of trauma-informed care city-wide in a Southern, urban metropolitan area

CFIR Domain	Construct Description	Finding synopsis	Example Quote
Characteristics of individuals		Difficulty confronting bias and TIC resistance	"people from a marginalized group assume that they wouldn't have implicit bias against another marginalized group […] to me is the biggest [barrier] with staff to get them to look at their own implicit biases." (Transcript 28)
Inner setting	Culture: Norms, values, basic assumptions in environment related to mission and purpose	Culture of acceptance	"Stigma is a part of a lot of the conversations that we have on a regular basis"[to]"establish a culture of respect for our patients and acceptance of our patients… We're not here to change anybody. We're here to help them live the best life that they possibly can live.” (Transcript 2)
		System of re-traumatization	"people are afraid of speaking up about injustices or ways that we're re-traumatizing staff because they are experiencing it from the very people in leadership and administration […] Even efforts for promoting diversity, that's a buzzword for leadership these days. Yet, that promotion of diversity never seems to be for leadership positions…That's the issue with white privilege and systemic racism is that the people and the power to change that don't want to give up their positions." (Transcript 1)
	Networks and Communications: Quality of internal social networks/communications influencing system	Need for patient involvement in decision-making	"I think when you just start to design programs without any insight from those that are actually affected, you just lose that patient experience […] because you're not really addressing any of the stigma. You're not addressing any of the patient's lived experiences in your building programs…” (Transcript 14)
	Implementation Climate: Tension for Change: Degree to which stakeholders perceive status quo as intolerable	Turnover damages client-provider trust	“I think clients know that they can trust us and we have their best interest at heart, and they know those of us who they can come to, but I think if we had a little longevity in staff, turnover rate wasn't as high, it would help with the trust factor, because they just don't establish it, you know what I mean?” (Transcript 35)
		Stigma around psychological health	"Many of our clients […] live day to day […] just addressing […] shelter, food, water, those things, and psychological and mental health needs tend to get put on the back burner a lot, but we know if those things don't get addressed, everything can crumble. […] but a big barrier is so much stigma surrounding psychological health and wellbeing.” (Transcript 32)
	Compatibility: Alignment with personnel norms, values, perceived risks/needs, fit with workflow/systems	Trauma is pervasive among clients	"Every client who comes in has some sort of trauma, even if that trauma is just being diagnosed with HIV…" (Transcript 32)
		Strong need to resist re-traumatization	“[patients] have a tendency to relive their trauma. […] It will overwhelm them sometimes and cause them to make not the best choices when they're in a pressure situation. I think that given the correct guidance and tools, they would make better decisions […] and try to make sure that if anything happens like that […], they're not triggered into making bad decisions again." (Transcript 25)
	Learning Climate: Open communication promoted via leadership transparency/collaborative decision-making, with comfort to disagree, unpack implicit biases, and on-going learning and reflection are prioritized, resulting in increased personnel perceived value and safety	Importance of transparency	"Consistency and transparency, willing to just be open about what's actually going on in the agency and creating a space that we can provide feedback and that be taken in, but I think a lot of times they are reluctant to share certain information due to whatever reasons. And so we don't know what's going on." (Transcript 35)
		Actions hinge on staff’s ability to voice opinions	"One area where I struggle is when I see unconscious bias happening. They're my coworker. So calling it out affects that relationship […] the best way to enact change in that is not just having trainings, but also calling it out when you see it.” (Transcript 1)
	Readiness for Implementation: Leadership Engagement: Commitment/involvement in TIC and prioritization of staff wellness	Need for stronger leadership engagement	"When you think of leaders in organizations that want to do the right thing, they have to truly understand that if they don't do this work, how it's going to affect not only the constituents, and the clients, and patients that they serve, it's also going to affect their personnel and their institution.” (Transcript 27)
	Available Resources: Resources dedicated to TIC: funding, training, space/time, personnel, referral networks, screening/assessment tools, programs/services/policies	Benefit of on-site Behavioral Health	"Having behavioral health integrated is also a way of acknowledging and addressing stigma, having all these services under one roof is an intentional way of reducing stigma.” (Transcript 1)
		Need for more referral sources	"Not knowing […] or having an immediate referral source. […] it's traumatic for everybody, the providers as well as the clients […] not being educated on the next steps, so to speak, that could support someone going through something like that." (Transcript 20)
Outer setting	Patient Needs and Resources: Extent to which patients’ needs are known/prioritized system wide	Benefits of one-stop shop approach	"What I hear from clients is they know the minute they walk in, they're not going to face discrimination. They don't have to worry about disclosure. Because they can get medical treatment here, behavioral health, case management, pharmacy services, I think having that physically under one roof starts to create that space of physical safety." (Transcript 1)
		Mental health care is a conduit for all care	“…substance abuse […] pretty much takes over someone's life. So if they're not getting the help with substance use or mental health, then they're probably not worried about taking their medications." (Transcript 31)
	Cosmopolitanism: Degree to which care organizations are networked to meet client needs/support TIC	City-wide collaboration can create comprehensive services for clients	"Nashville has fairly strong nonprofits that come in and help provide social supports, but I'm not sure that we have a real strong network of how do we connect with them.” (Transcript 4)
		How the goal of EHE guides our work	"What I'm hoping grows from this is a better conversation amongst the players in Nashville and the process issues […] individualized training and cultural humility is an incredible step, but we've got to get our systems and processes smoothed out, because we re-traumatize our patients […] we need better hand offs. So, my hope, in the epidemic, I think we have to grow from TIC to better systems, and processes, and handoffs." (Transcript 4)
Process	Champions: Individuals appointed/volunteered to bear responsibility for or who influence TIC implementation	Perception TIC is an opportunity for growing city-wide care	"We desperately need it [TIC] because we definitely need to do better. And servicing our clients. […] we definitely could do a lot in servicing the whole person.” (Transcript 12)
		Recommendations for TIC roll out	"Really diversifying the ambassadors and the champions for trauma-informed care is […] critical moving forward.” (Transcript 27)
Intervention characteristics	Relative Advantage: Status quo and perceived impact of TIC on staff wellness and client services	Need to further support patients with trauma	"this is one of the best things that I think that has come along in a very long time […] the underestimation of what a person has gone through is one of the biggest barriers that we face for being able to take care of patients.” (Transcript 5)
		Efforts should be tailored to our metro system	"You need to listen to the people when you're developing programs. […] You have to make it unique to this Metro community, and I think that we make a lot of mistakes where we think something works somewhere else […] and then we bring them and we apply them, and we think that's going to take care of the problem. That's been our biggest downfall." (Transcript 27)
	Complexity: Perceived difficulty of implementation (navigating systems for trauma service provision)	Working within larger systems	"In a perfect world, we would give patients a voice at the table [to have] decision-making authority… We're a clinic that operates within a larger corporate structure. […] there're extreme limitations on what we can do, what authority patients have over this clinic, […] in my ability to initiate new programs." (Transcript 4)
		General resistance to change as another thing “to do”	"Change is tricky and hard for a lot of people, and it's really easy to just continue doing things the same way […] one of the biggest barriers is buy-in, but once people understand that these things are real and tangible and will actually help us in our jobs, that's where the success is." (Transcript 32)
		TIC training must be on-going	"Training for TIC is not a one and done process. […] It's a continuous process of reevaluating and retraining. So, we currently don't have a system where every 6 months we're checking in, or a few months checking in, and making sure that everyone has the same access to the same information." (Transcript 1)
		Barriers to culturally responsive TIC	"The white privilege, the power and control of folks that don't understand their own privilege and acknowledgement are going to continue to be, I think huge barriers, and I mean, all from funders, to board, to leaders, to institutions where you refer clients, where clients receive services, it's all the white privilege system." (Transcript 27)

Table demonstrates findings from key informant interviews with personnel from five institutions providing HIV care throughout a city region. Construct descriptions show how constructs from the Consolidated Framework for Implementation Research (CFIR) 1.0 relate to trauma-informed care

Characteristics of individuals

Participants reported prioritizing patient-centeredness, trauma sensitivity, and attentiveness to fostering safe, supportive environments. Most felt prepared to respond to patient trauma due to years of professional experience, education, and/or their own trauma experiences or membership within marginalized groups. All participants expressed support for TIC implementation and commitment to continuous learning to improve services, endorsing attention to behavioral health care as central to EHE goals. Some participants felt under-prepared to deal with patient trauma and/or confront biases due to personal trauma, compounded stress of frontline work during COVID-19, challenges related to working in a state where policies are perceived as oppressive toward minority populations, and general lack of trauma knowledge/training.

"I could have been better prepared if I had deeper experience providing direct services myself […] when you are in the trenches working with patients or clients, you learn so much more and grow. And so, that would've helped me, I think, understand some of the complexities that my staff are dealing with."-Transcript 4: clinic leadership

Inner setting

Culture

Organizational environments were described as inclusive but sometimes lacking leadership diversity. While staff diversity was believed to be prioritized through hiring practices, with staff demographics often mirroring populations served, there was an observed lack of representation among clinicians, therapists, and leaders, which was seen as under-prioritized among upper management and a source of re-traumatization among personnel and clients. Despite this theme, the culture of care environments was described as mission-driven, nonjudgmental, and patient-centered with policies/practices that promote autonomy, upheld by compassionate staff who build trust through mutual accountability, appropriate language/tone, protection of confidentiality, efforts to combat stigma/discrimination, and a trauma-sensitive service lens.

“showing them [clients] that they can trust us […] by just having the amazing staff that we have and building rapport and building relationships with people, and knowing that we have resources.” -Transcript 32: CBO provider

Networks and communications

Overall, internal communication systems were perceived to be effective in deescalating crises and supporting clients, but some participants reported fragmented teams and poor communication during crises. Consumer feedback was informally captured during routine visits and shared in team meetings. Detailed intake assessments, advanced care plans, and mental health screenings were seen as important means of gathering/sharing information to optimize care. Opinions on electronic medical records elicited mixed perspectives with some advocating for less visibility—to protect client confidentiality, while others wanted greater visibility—to avoid duplicative history-taking as potentially re-traumatizing. Patients were nominally involved in organizational decision-making through community advisory boards (CABs) and ad hoc feedback surveys, which were cited as having unclear language, low client engagement, and poor representation among difficult-to-reach clients. Similarly, CABs faced limitations such as scheduling conflicts, lack of compensation, and insufficient management support. Some noted feedback was often garnered from selected clients. The need for systematic and comprehensive consumer involvement and representative feedback was highlighted as necessary for a successful TIC program, with an emphasis on enhancing engagement among persons with lived experience.

"Sometimes the peer team [is] overlooked in terms of what's really happening with the clients. […] because the clients feel more comfortable with us, they will really tell us a lot more, which would help with helping them with their issues..."-Transcript 29: CBO leadership

Implementation climate

Tension for change

Extant trauma screenings were seen as not comprehensive, universal, or routine, with a need for better trauma screening tools and documentation. Most identified a need for more trauma support services. Difficulties in building client trust were seen as connected to clients'past negative experiences with providers, unaddressed mental health, high staff turnover/burnout, client disengagement related to provider apathy/racial tension between client/provider, provider perception that patients often do not progress, and a lack of client privacy with too many assigned providers. One person emphasized that the limited amount of time providers get to spend with clients furthers this divide:

"People may often come to us with a history of not being able to trust medical people. […] you get about 15 seconds when you walk in the room with that patient to establish a good relationship with them."-Transcript 8: clinic leadership

Compatibility

Participants reported that in addition to providing “excellent” clinical care, they work to destigmatize mental health services, foster trauma-sensitive spaces, and enrich interpersonal care by offering peer support groups among PWH. Trauma was seen unanimously as pervasively affecting clients, and TIC was recognized as a means to optimize care, with a TIC coordinating program as a method for improving adoption. Many described services as inherently trauma-informed but stated a need to prioritize staff wellness to improve retention of staff working directly with traumatized patients while coping with primary trauma.

“[W]e could use trauma-informed care here to help the clients and measure client psychological wellbeing […] in supporting staff psychological wellbeing […] it would be very valuable for clinics across the board.” -Transcript 10: clinic leadership

Learning climate

Participants reported several facilitators to addressing implicit bias in the workplace including open communication in staff meetings, comfort with healthy disagreements, and a climate of continued learning. Past trauma trainings were described as culturally inclusive and well-explained in comfortable environments, which were facilitative of meaningful discussions that improved provider confidence. Having supportive, available supervisors who value discussion and feedback and are familiar with staff responsibilities were noted as ways for personnel to feel heard and appreciated. However, some cited leadership issues in engaging staff, including a lack of follow through on suggestions, change-resistant leaders who are disconnected from frontline work and fail to incentivize/compensate for additional work, and a lack of leadership diversity. Overall, championship among leaders was seen as critical for promoting a social learning environment where microaggressions could be addressed, with one person stating:"…if you voice something, you feel like you're going to definitely offend someone, so nobody really does anything, it never gets addressed."-Transcript 31: CBO leadership.

Readiness for implementation

Leadership engagement

There was a divide between how leaders viewed their level of support for TIC versus front-line workers’ view of their support. Leaders expressed support, while also acknowledging perceived implementation barriers (e.g., lack of capacity/funding), such as prioritizing staff wellness and a workforce with lived experience. Direct care providers expressed that leaders were aligned with TIC when they had open-door policies or had experience serving in direct care positions. Many noted there had been trainings, workshops, and/or discussion of TIC in meetings. Others felt that work-related trauma was not acknowledged by leadership, attributing high turnover rates to poor staff wellness, and expressed need for more transparency in organizational decision-making. Some felt that if a TIC program would be successful, greater leadership support was necessary, as was inclusion of community-designed initiatives. Some suggestions included,"Doing it [TIC committees] during clinical hours, so not expecting people to work for free during their afterhours […] allowing your staff to leave the clinic and be done with their job when they're supposed to and not expecting them to work after hours.” -Transcript 1: clinic provider.

Available resources

Many credited confidences in providing client care to a wealth of organizational resources and trainings but suggested changes for future trainings included a need to make them reoccurring and incentivized (e.g., compensation or continuing education credits). Some organizations provide a comprehensive “one-stop-shop” approach with several services available to clients within the same site. Participants viewed integrated onsite behavioral health services as a major benefit to staff when guiding patients through trauma and crises. Methods for promoting client safety included onsite services (e.g., security, mental health) and policies and procedures to promote respect and confidentiality. Some participants credited the work of committees, agency equity statements, and policies as assets for delivering culturally responsive services. Participants mentioned the need for onsite behavioral health, printed TIC materials, staff-wide training to handle mental health crises, and increased staffing (especially Spanish-speaking practitioners and therapists of color). Most participants identified capacity issues (e.g., short session times, lack of behavioral health clinicians) as barriers to addressing mental health, building trust, providing information, and empowering clients.

"Not having a licensed psychosocial clinician available […] on staff period. I think that having that presence of that individual could support and help out our clients because […] they come in with a wide variety of immediate needs. A lot of it is trauma based. I think [we need] a licensed clinician available, however many hours a week."-Transcript 20: CBO provider

Outer setting

Patient needs and resources

Some participants viewed telehealth and online counseling as facilitators to meeting client mental health needs and increasing engagement, especially for those with transportation barriers. Generally, receiving mental health care was viewed as a conduit for promoting engagement in all care. Barriers to providing care include clients’ unstable/unsafe home environments (e.g., intimate partner violence and housing challenges for clients with felonies); perceived judgment about medical adherence lapses; HIV stigma; and misinformation about HIV and sex education among family, friends, and PWH themselves. There was a collective awareness about the need to screen and treat trauma (as a primary contributor to patient disengagement and sub-standard adherence to care regimens), coupled with a recognition that mental health resources were lacking.

“If a person doesn't go to the doctor on a regular basis, for whatever reasons, lack of trust of the provider, we look at that as a failure, versus really trying to understand that. […] but I think that a lot of people that have been lost to care, if we unpack that, there's more to just them not being able to have transportation to go to see their provider.” -Transcript 27: CBO leadership

Cosmopolitanism

Many participants feel confident in providing services due to their knowledge of referral networks and relationships with community partners. However, some mentioned an overreliance on community partners, feeling ill-equipped to make referrals due to a lack of familiarity with external services, and the perception that institutions operate in silos from another. System-wide barriers to care include long wait times for external mental health support and insufficient HIV prevention resources. With federal regulations (i.e., HIPAA) complicating patient referrals and follow-up with community partners, many suggested a universal release of information. Collaboration among different organizations and across disciplines was seen as essential to the success of TIC adoption and EHE goals.

“…[I]ndividualized training and cultural humility is an incredible step, but we’ve got to get our systems and processes smoothed out because we re-traumatize our patients when they have to re-disclose everything that they had just disclosed […] We have to grow from TIC to better systems, and processes, and handoffs.”

-Transcript 4: clinic leadership

Process

Champions

Some organizations have various committees serving as internal advocates for TIC and collaborating with external professionals. Participants discussed that more engagement from leadership, human resources, and equity teams is needed to promote cultural responsiveness. For city-wide TIC support, it was noted that the key to appealing to community engagement was to increase diversity among TIC champions. Many also expressed need for a city-wide TIC program that could be uniformly applied across organizations as a mechanism for actionizing united EHE goals.

"I think that a big barrier right now […] anybody that's been public health with STD and HIV, we should all be linked in together. We should all be on the same page"-Transcript 13: health department provider

Intervention characteristics

Relative advantage

TIC and cultural responsiveness trainings have helped participants respond to clients more confidently, but a greater focus is needed on personnel trauma. Some believe a city-wide effort to adopt TIC should be balanced with other priorities, such as meeting clients’ basic needs. Others cautioned that the success of TIC programs rests on its relevance to the local community and the diversification of champions.

“You need to listen to the people when you’re developing programs […] You have to make it unique to this metro community, […] we make a lot of mistakes where we think something works somewhere else […] and then we bring them and we apply them, and we think that’s going to take care of the problem.”

-Transcript 27: CBO leadership

Complexity

Participants anticipated experiencing challenges related to working within large, bureaucratic institutions, given the complexities of implementing a multi-level intervention. They saw hierarchies as barriers to collaborative decision-making, with financial and political considerations potentially being prioritized over patient-centered care. In some institutions, racism and inequity was described as part of leadership hiring practices and organizational structures of privilege. Some participants noted difficulties related to systems-level change, such as general resistance to change, but also related to efforts to alter deep-seated beliefs, and stigma complicating client confrontation of trauma.

“We're a clinic that operates within a larger corporate structure. […] And so, there're extreme limitations on what we can do, what authority patients have over this clinic […] I have extreme limitations in my ability to initiate new programs.” -Transcript 4: clinic leadership

Phase III: summit implementation recommendations

Of the 17 individuals who attended the dissemination summit, 10 (59%) were Black and 7 (41%) White; 15 (88%) female and 2 (12%) male. Personnel included 5 (29%) direct care providers and 12 (71%) administrators, with 3 (18%) persons either living with or affected by HIV. Types of positions represented included a physician, psychiatric nurse practitioner, researchers, HIV testers and educators, executive directors, case managers, community health workers, and other administrators. Attendees had an average of 13.6 years working in the field of HIV, with 191 years of collective experience. Summit participants discussed findings from the key informant interviews and made the following four overarching recommendations and relevant strategies, with strategies 1–3 focusing on all six TIC principles, and the fourth recommendation focusing on the sixth principle of Cultural Responsiveness.

1) Create a city-wide coordinating center with a shared communication system to facilitate networking, referrals, access to resources (e.g., mental health care, wraparound services), and educational opportunities. Strategies discussed included convening routine cross-agency meetings for case conferencing, leveraging pre-existing dashboard-type models, and creating a clearing house for uniform training across the network. 2) Build a wellness campaign for HIV care personnel. Strategies include providing on-site behavioral health support for employees and/or providing a mental health hotline for personnel (i.e., not relying solely on employee assistance programs with scheduling and co-pay barriers). 3) Routinely conduct evaluations to elicit patient and personnel feedback to inform policies and practices. Strategies include adding a step in the HIV care cascade for behavioral health, assessing organizational performance using TIC metrics (e.g., perceived safety of care environment), consistently evaluating personnel professional quality of life, and assisting all care organizations in the network to uniformly evaluate programs. 4) To foster cultural responsiveness, prioritize and instill humanistic communication. Strategies include diversifying leadership and practitioners, screening for cultural sensitivity when hiring new personnel, applying strengths-based models for patient care, and providing consistent staff trainings with experiential activities to model open dialogue.

Discussion

We applied a CBPR approach to collaboratively conduct pre-implementation stage research to inform a data-driven TIC implementation plan for a metro-wide HIV care network. Results indicate there were limited trauma assessments and services in the network, but there was tension for change and an implementation climate compatible with TIC. There was an observed need for scaling up trauma services, implementing personnel trauma training and wellness initiatives, increasing systematic efforts to design patient-centered care, diversifying leadership championship, prioritizing cultural responsiveness, and leveraging resources to coordinate city-wide efforts. Findings expand HIV-trauma syndemic knowledge relative to potential TIC implementation strategies and the explicit role of cultural responsiveness. While we believe this is the first study to qualitatively explore implementation determinants of a city-wide, trauma-informed HIV care network, the observed need for greater collaboration across the network is consistent with TIC literature in other settings [18, 25], underscoring the importance of network-level and multi-disciplinarian implementation efforts.

Though trauma services were a voiced priority, due to the identified pervasiveness of trauma, they were limited. There was a noted cost of not implementing TIC in a system that insufficiently addresses mental health. Most (75%) HIV-focused CBOs in the Southern U.S. report insufficient community mental health services, with only 43% reportedly having routine procedures for patient trauma screening [32]. Our findings appear consistent with national [25], regional [33], and local findings, with the latter also indicating the need to improve the quality of mental health services [8]. Consistent with literature [26, 32, 42, 45], we observed significant interest in TIC adoption within a workforce with little trauma training. These results highlight the need for carrying out summit recommendations for generating a united network approach (i.e., for shared networking, referrals, and trainings).

The noted need for greater staff wellness initiatives echoes other literature [26, 45] and presents as a modifiable aspect of professional quality of life [46, 47]. While HIV care personnel report high levels of burnout [26], only one-third of CBOs reportedly address personnel vicarious trauma [33]. This is a critical omission given the trauma burden experienced by PWH and likelihood for vicarious trauma [48]. Staff wellness campaigns excluding mental health have been ineffecitve [49, 50], but those including mental health support have proven effective in various settings [46], as associated with reductions in stress, anxiety, and depression and improvements in well-being [47]. Hence, improving staff wellness not only presents as important but likely feasible.

Similar to other Southern CBO’s [33], there was an observed need to systematically engage community members/end-users as collaborative designers of services and policies. Although a recent quantitative study shows a high rate of personnel reported patients are invited to share their ideas and experiences [45], there is need to better tease out if “feedback” is systematic versus informal, and if suggestions are integrated into services. As scant research focuses on methods to engage community members/end-users in HIV research [51, 52], our efforts to co-produce [44] TIC implementation appear to be unique but could be salient given the observed unity in the summit.

Current findings contribute to the growing operationalization of the Sixth TIC principle as cultural responsiveness. Our findings suggest cultural responsiveness is critical in HIV care settings, marking the first evidence of this kind for TIC in HIV care. However, strategies raised during the summit (e.g., diversifying leadership and practitioners, screening during hiring procedures, providing consistent personnel trainings) are similar to many of those presented in recent literature on the role of antiracism in TIC [53]. The applied participatory approach and analysis of network-wide determinants represent strong mechanisms for promoting culturally responsive research, especially given the raised sentiment that the success of a single institution undergoing cultural responsiveness initiatives would be potentially tempered if the whole system did not fully participate. This finding aligns with a conceptual article depicting the importance of cultural responsiveness as part of a city-wide effort to implement TIC within public health [5].

Summit recommendations produced several potentially innovative solutions for macro implementation. While CFIR has been applied to assess TIC implementation determinants [42, 54], little attention has focused on mesosystems [55] or the interplay between multiple institutions’ inner setting factors and the gestalt of an outer setting. Despite the summit including historically fragmented institutions (e.g., often competing for the same funding), there was a transcendental unity of mission, purpose, and fervor for jointly addressing the emotional wellness of PWH and care providers as a shared community. The city-wide coordinating center appeared as a novel capacity-building strategy for furthering this spirit of unity and resource-sharing.

Several factors could boost the feasibility of city-wide implementation relative to funding, platforms, and sustainability. Roll-out efforts could be enhanced if they were matched with pre-existing macro-level initiatives, including federally-funded AIDS Education Training Centers, Centers for AIDS Research, or EHE plans. With a primary mission of workforce development, AETC initiatives could house a macro-level training intervention as part of the AETC mission and purview. For example, a micro-training series could be produced to educate HIV care personnel on the HIV-trauma syndemic and effective methods for resisting further traumatization. Personnel and patient outcomes could be tracked over time as part of EHE plans to progress improvements in patient- and personnel- level outcomes. Further, connecting these efforts to CFAR projects, goals, and resources could ensure there are investigators to maintain focus on implementing interventions and evaluating change efforts to enhance reproducibility/replicability. Some of these change efforts might include personnel wellness campaigns and memorandums of understanding to allow data- and resource- sharing. Involvement of CFAR faculty would enable greater leveraging of expertise (e.g., biostatistics, trainers, investigators), as compared to only one clinic or institution housing these efforts, and the overall mission of addressing the HIV-trauma syndemic could remain prominent within stated goals of CFAR research strategies. Finally, by housing TIC implementation, dissemination, and sustainment under these entities, a collaborative approach would actualize, potentially preventing the project from being viewed as “owned” by any one institution within the system.

Limitations

This study has limitations. First, we employed purposive sampling that could have led to biases (e.g., readiness for TIC). However, recruitment strategies were designed collaboratively, which likely reduced selection bias. Second, the unit of analysis was city-wide themes due to the interdependent nature of shared clients and resources. Thus, some unique features of individual institutions may not appear thoroughly here. We intentionally did not ask study participants about their HIV status, as to reduce the pressure of serostatus disclosure. In addition to several summit participants vocalizing having a positive serostatus, summit participants were generally representative of the local HIV care workforce, relative to position type, demographics, and years of experience working with HIV care. Finally, some of our findings may not be generalized to other HIV care settings, as metro areas face different barriers to TIC implementation. However, much of our results are consistent with other findings in HIV care settings in the South. Future research should explore how city-wide findings might differ from individual-level findings and how barriers and facilitators might differ in various regions of the U.S. Further, our theoretically-driven process, underpinned by implementation science and participatory methods, could be replicated by other TIC champions seeking to develop community- and data- driven implementation in large networks.

Conclusions

We developed a community-created and data-driven implementation plan to guide culturally responsive TIC throughout Nashville’s HIV care network. Current TIC standards were explored, as were personnel-perceived determinants of TIC implementation. A dissemination summit was convened to validate findings and generate a collaborative plan for future implementation. Findings contribute meaningfully to the growing body of TIC-HIV knowledge by showing the need to scale up trauma trainings, services, personnel wellness initiatives, and cultural responsiveness. Results suggest high levels of need for and compatibility with TIC across the Southern HIV care network. Future research will focus on maintaining community engagement to collectively guide TIC implementation. Researchers interested in co-produced TIC research may consider similar methods to promote trauma-informed research.

Authors’ contributions

Authors contributed the following: LLB, JT, CB, MH, BH, AP conceived the study and sought and received funding to support it. LLB wrote the first draft. LLB, JP, JA, JLS, MH, JMS, and ACP revised the manuscript. LB, JT, CB, MH, JLS, AO, LA, AD, TL, AC, JSK-K, JH, and ACP edited the PM figure. LLB, JA, JLS, JMS, and ACP edited the table. LLB, CB, MH, JLS, AO, TS, LA, AD, TL, AC, RN, MA, JS, NF, BGJ, JH, and ACP participated in the summit. LLB, JP, JA, JT, CB, MH, JLS, JB, SS, JVDE, BH, AO, TS, LA, AD, TL, AC, RN, MA, JSK-K, NF, BGJ, JH, CA, JMS, and ACP edited drafts and approved of the final manuscript.

Funding

This project was supported by a Developmental Core Award (P30 AI110527) via the TN Center for AIDS Research; LLB acknowledges salary support from NIH K01MH131471-01 A1; JMP acknowledges salary support from NIH K01MH115811; ACP acknowledges support from MH113438 and P30 AI110527.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Ethics approval was provided by Meharry Medical College Institutional Review Board (21-05-1091) and Metropolitan Health Department of Nashville (protocol 2021004) under 45 CFR 46.110 (F) Category (7). All methods were carried out in accordance with these IRB guidelines and regulations. The Meharry Medical College Institutional Review Board deemed process map and dissemination summit activities did not meet the criteria for research and waived the need for informed consent from subjects, however, full consent procedures were completed for all one-on-one interviews.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.