Adolescent Perceptions of Organizational Trauma Resilience in an HIV Clinic: A Convergent Parallel Mixed Methods Design Study

Abstract

Background

Shelby County, Tennessee (Memphis) has the highest rate of HIV incidence in the country, and youth in the region are disproportionately impacted. Local plans to end the epidemic call for implementation of trauma-informed care (TIC).

Methods

We conducted a convergent parallel mixed methods study, including interviews and surveys, with adolescents receiving care in a youth-focused HIV clinic in Memphis.

Results

Almost half (47%) of participants met the criteria for probable PTSD, with 30% meeting criteria for provisional PTSD. Participants reported the clinic was aligned with TIC principles (i.e., sense of trust, support, collaboration, safety, and inclusivity) and unanimously voiced support for integration of trauma screenings and assessments. Important recommendations were also raised for implementation, with attention to cultural responsiveness and peer support.

Conclusions

Findings show a positive perception of the clinic. Follow-up research will be used to inform the development of a trauma-focused intervention to influence HIV health outcomes.

Plain Language Summary

Youth in Shelby County, Tennessee (Memphis) endure a disproportionate HIV burden, compared with youth in other parts of the United States. Local plans to end the epidemic call for implementation of trauma-informed care (TIC) to ensure youth with HIV receive adequate mental health support. To help guide a youth-tailored plan for implementing TIC in one adolescent-focused HIV clinic in the region, we conducted a convergent parallel mixed methods study, including interviews and surveys. Results show 30%-47% of sampled youth with HIV met criteria for PTSD; the clinic was seen as having a culture that is aligned with TIC principles (i.e., sense of trust, support, collaboration, safety, and inclusivity); patients unanimously voiced support for trauma screenings and assessments; and recommendations were provided for cultural responsiveness and peer support. Findings will inform the development of a youth-focused TIC implementation plan, designed to influence HIV health outcomes.

Introduction

Shelby County, Tennessee (TN), with Memphis as the county seat, ranks first in the country for new HIV infections, ¹ where youth (aged 15-24 years old) have >4 times higher rates of new HIV cases compared with the national average. ² As such, Memphis is situated in a nationally prioritized jurisdiction for ending the HIV epidemic (EHE) in the United States (U.S.)^3,4 Treatment-as-prevention is an important strategy for ensuring that youth with HIV (YWH) remain adherent to antiretroviral therapy, virologically suppressed (undetectable), and unable to transmit the virus to others. ⁵ Hence, HIV appointment adherence is instrumental in promoting this treatment-as-prevention approach, while non-adherence to appointments poses a major threat to consequent viral transmission and morbidity.^6-10 Compared to people of all ages with HIV, YWH are more likely to miss HIV care appointments, ¹¹ with 36% having missed two or more visits with their HIV care provider in the last year. ⁶ Compared with White YWH, Black YWH are >70% more likely to miss HIV appointments, ⁶ contributing to downstream disparities such as a >two-fold decrease in likelihood of viral suppression. ⁷ Efforts to improve HIV outcomes are particularly urgent in Memphis, where there is need for interventions that effectively address drivers of missed appointments.

The HIV-trauma syndemic^8-10,12-17 indicates psychological trauma—or lasting effects of adversity^8-10,12— among youth correlates with psychological sequelae and non-adherence to HIV care.^13-15 YWH overall experience an average of six traumatic events and extremely high rates of post-traumatic stress symptoms (47%). ¹³ Black youth experience on average an additional ∼6 instances of racism annually, ¹⁸ intensifying traumata ¹⁹ among Black YWH. In the Southern U.S., YWH endure high levels of adversity (e.g., verbal abuse, physical abuse, sexual abuse), ²⁰ resulting in missed HIV care appointments. ¹⁶ Despite this syndemic, HIV-trauma interventions to modify appointment adherence among Black YWH are lacking, representing major equity gaps in HIV care.

According to the Substance Abuse and Mental Health Service Administration’s Treatment Improvement Protocol 57, ²¹ Trauma-informed care (TIC) is an evidence-based approach for Resisting re-traumatization via trauma Response.^22,23 Organizational Trauma Resilience (OTR) is a framework for measuring fidelity to a TIC paradigm, specifically focusing on the extent to which patients and personnel perceive the care environment to be safe, stable, and nurturing as measured through six dimensions: Culture of trust and support; Practices of inclusivity, safety, and wellness; Collaboration and empowerment; Trauma-responsive services/Training and Sustaining a trauma-responsive workforce; and Cultural responsiveness/Fairness and Respect.^24,25 Many studies indicate TIC protocols improve youth programs ²² relative to 1) patient service engagement, satisfaction, and Post-Traumatic Stress Disorder (PTSD) rates; 2) provider knowledge, satisfaction, attitudes, and stress; and 3) system-level collaboration, number of providers trained, and leadership culture. TIC integration into HIV care is a priority^3,9,24,26,27 set forth in Memphis’ local EHE plan, which was developed via federal funding to reduce new HIV infections in Shelby County by 2030. ³ Thus, while the local plan for curbing HIV infections specifically cites need for TIC integration, TIC infrequently appears in HIV research and has yet to be adapted for YWH in the region. ²⁸ We sought to understand the perspectives of patients (YWH) and personnel from one youth-focused HIV clinic, which is the primary HIV care provider for YWH in the Memphis region, to guide context-tailored implementation of TIC in the clinic.

Methods

We applied a convergent parallel mixed methods study design ²⁹ to explore patient perceptions of current practices and conditions related to OTR. Guided by the OTR framework, qualitative interviews were conducted to deductively understand patient experiences and were followed by a quantitative survey to characterize practices, conditions, and cultures relative to OTR. Qualitative and quantitative findings were then compared vis-a-vis to provide a synthesized depiction of patient perspectives relative to OTR. Research questions included: 1) How do patients perceive current standards of care along the OTR framework? 2) What are the quantitative levels of OTR observed? And 3) In what ways do qualitative and quantitative results converge or diverge?

Interviews

An interview guide (Supplemental File 1) was developed to explore perceptions relative to the dimensions from the Organizational Trauma Resilience – Patient Reported Experience Measure (OTR-PREM) index. This index includes two scales: Organizational Credibility and Culturally Responsive Trauma Resilience. Interviews relied on a convenience sample and eligibility criteria included: 1) current patient or family member of a patient, 2) could participate in English, and 3) could provide consent prior to voluntarily participating. Interview participants were recruited during routine comprehensive medical appointments via flyers or face-to-face recruiting. Interviews were conducted by two external interviewers not affiliated with the clinic. The interviewers were female research assistants trained in TIC and research approaches. Participants completed informed consent prior to beginning interviews. Interviews were conducted one-on-one via a secure audio-visual virtual platform. Interviews lasted about 30 minutes and were audio recorded and transcribed verbatim. Participants received a $50 gift card following completion of the interview. Saturation was assessed at two time points: after 9 interviews were complete and after the final interview. According to Hennink and Kaiser (2022), ³⁰ this is an appropriate sample size for reaching saturation, with most studies reaching it between 9-17 participants.

Analysis of interviews was conducted by four coders, with three coders taking the primary role and one as a supervisor of the process. Two primary coders developed a codebook, using the OTR-PREM. The codebook organization and co-designing definitions and differentiations were based on how data fit best into the OTR-PREM dimensions. Three coders independently coded each transcript using thematic analysis so that each quote was assigned an OTR dimension as a theme, with no overlapping codes applied to the same segment. To track coding reliability, matrices were developed and independently applied by coders to produce Kappa scores by dimension. Consensus was considered if two out of three coders utilized the code. If only one utilized the code, this was considered an inconsistency, contributing negatively to the Kappa score.

The final codebook can be found in Supplemental File 2. In summary, for Organizational Credibility, the Kappa statistic was 0.886 (p=<0.001). Sub-dimensions had similar Kappa statistics with a few noteworthy distinctions, including Culture of Trust and Support (Kappa statistic= .946; p=<.001), with coding application centering on culture as a concept that expands beyond interactions with one or a few staff members and physical safety. Practices of Inclusivity, Safety, and Wellness had a Kappa statistic of .793; p=<.001) and codes centered on practices that demonstrated patient emotional safety and choice as priorities (as opposed to implicit feelings or physical safety). Finally, for Collaboration and Empowerment, the Kappa statistic was .886 (p=<.001) and codes centered on documenting the extent to which services are collaborative between patient and providers in addition to the dynamics between providers in the clinic.

For Culturally Responsive Trauma Resilience, the Kappa statistic was .919; p=<.001). Sub-dimensions had similar Kappa statistics also with a few noteworthy distinctions, including Trauma Responsive Services, with a Kappa statistic of .823; p=<.001 and codes centering on trauma services and practices provided. For example, results were coded if trauma services had been offered or coordinated (rather than on the quality of the service). Impact of Provider Training had a Kappa statistic of .913; p=<.001, with codes centering on the quality and presence of trauma services; and if trauma services were not reportedly provided, centering on whether providers were inherently trauma-sensitive through demonstration of resilience or strength-focused behaviors. Finally, Fairness and Respect had a Kappa statistic of .919; p=<.001, with codes centering on the standard treatment of patients in the clinic, similar to Culture of Trust and Support, but integrative of how organizational culture demonstrates cultural responsiveness.

Finally, quotes were reviewed with a TIC steering committee comprised of personnel from the participating HIV clinic.

Survey measures

Following completion of interviews, preliminary interview themes were shared back with clinic personnel via routine in-person and virtual clinic meetings. A steering committee of clinic and ancillary personnel was convened to oversee further research activity relative to the implementation of TIC. Topic areas for the survey were informed via discussions with the steering committee, who collectively decided which validated questionnaires to include in the survey. Potential participants were recruited through verbal invitations or flyer distribution during routine clinic appointments. Eligibility criteria included: 1) being a current patient with a confirmed HIV diagnosis or family member, 2) able to participate in English, 3) at least 18 years old, and 4) able to provide consent prior to voluntary participation. Surveys were self-administered via Research Electronic Data Capture (REDCap). ³¹ Participants provided electronic informed consent prior to beginning surveys, which took approximately 30 minutes to complete, with participants receiving $25 gift cards for completion.

Measures included the Organizational Trauma-Resilience - Patient Reported Experience Measure (OTR-PREM), which is a 40-item index, using a five-point Likert scale with responses between 0 (Not at all) and 4 (Totally). The OTR-PREM index includes two scales: Organizational Credibility and Culturally Responsive Trauma Resilience, with each having three dimensions. Results are interpreted as scaled scores by taking raw scores for each scale and dimension within the index and dividing them by the number of items in the dimension, with 4 as the highest possible score and associated with greater levels of perceived organizational trauma-resilience. ²⁵ In the current study, the Organizational Credibility and Culturally Responsive Trauma Resilience scales showed Cronbach alpha coefficients of between .992-.987, respectively, and means of Corrected Item-total Correlation of between .876-.882.

The Short Post-Traumatic Stress Disorder Rating Interview (SPRINT) instrument was used to measure probable PTSD symptoms. ³² It is an 8-item scale with Likert scoring per item (“0” corresponding to “Not at all” and “4” corresponding to “Totally”). Scores range between 0-32, and a cutoff score of 13 and above is used to indicate probable PTSD. ³² In the current study, the SPRINT instrument had Cronbach alpha coefficient= .928. Consistent with instrument scoring, ³³ the first 15 items of the International Trauma Questionnaire were used to assess PTSD symptoms and had a Cronbach alpha coefficient of .940 with a mean of corrected item total correlation of .696. A provisional diagnosis was assigned if participants met relevant cutoff criteria for PTSD via both instruments. Participant demographics were captured using the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). ³⁴

Descriptive statistics were used to analyze survey responses. Frequencies and percentages were used to summarize responses for categorical variables and by dimensions of the OTR-PREM. PTSD scores were reported as percentages meeting the cutoff threshold.

Results

Sample

The participating institution had a current census of 188 patients living with HIV. Of those participating in the study (n=70), 60% were male, 34% were female, and 6% transgender. The majority were Black (89%), 4% Hispanic, 3% Biracial, or 4% Other/White. Most were between the ages of 18-24, with 7% under the age of 12 years and 11% between the ages of 12-17.

Interviews were completed by 13 participants. Interview participants were primarily same gender loving (75%) Black (100%) males (83%), with an average age of 22 and average length of time as a patient of 4.5 years. Two of the interviewees were family members of a patient, with one being a patient’s partner and the other a patient’s parent. Additionally, demographic information was missing for one participant. Patient demographic information presented as generally representative of the clinic patient population, with slightly more male representation than female.

Seventy-eight participants initiated the survey, and 70 completed it. Five of the qualitative interviewees were represented in the survey sample. Of survey participants, 71.4% identified as male, 90% identified as Black, and 6% identified as Hispanic; 36% identified as gay, 26% straight, 23% bisexual, and 16% other. Participants’ mean age was 21 (range = 18-24 years). Forty-seven percent (n=33) of the sample met the criteria for probable PTSD via SPRINT; 37% met the criteria for probable PTSD via the ITQ alone; and 30% met the criteria using both measures as a provisional diagnosis.

Quantitative Survey Results

Survey scores indicated the clinic was perceived to have a culture strongly aligned with OTR, with the Organizational Credibility scale showing the highest scores (scaled score of 3.55, with 4 as the highest possibility). While the dimension of Impact of Provider Training within the Culturally Responsive Trauma Resilience scale had the lowest score of all measured, it was still relatively high (3.30 out of 4). See Table 1 for summary scores by OTR scale and dimension. Results were descriptively similar within the Organizational Credibility scale (See Table 2). For Culture of Trust and Support, 93-96% of participants selected Agree for items from this dimension; for Practices of Inclusivity, Safety and Wellness dimension, 93-96% of participants chose Agree for these items; and for questions from the Collaboration and Empowerment dimension, 95%-96% of participants chose Agree. Some results within the Culturally Responsive Trauma Resilience scale suggested patients perceived the clinic to have lower performance in this area relative to others measured. For example, for Trauma Responsive Services, Agree responses ranged from 80%-96% on these items. Items of lowest agreement were: There are staff here who look like me or share a similar identity (80%), Staff here help me connect with other people who share similar experiences (84%), and Staff have asked me if I have experienced trauma (90%). Nonetheless, these responses suggested most patients felt the clinic demonstrated fidelity to these concepts. Results from the Impact of Provider Training dimension had the lowest Agree responses, with only 77% agreeing to Staff here treat me as though I have the ability to solve problems for myself; 81.5% agreeing to If I am ever angry or upset, staff here know how to help me calm down; 81.4% agreeing to Staff are sensitive to how I have personally experienced challenges in my life; and 91% agreeing that Staff set clear boundaries with me. Finally, results for the Fairness and Respect dimension were descriptively more similar to dimensions in the Organizational Credibility scale, with 91-94% of respondents Agreeing across items.

Table 1.

Dimension summary scores of the OTR-PREM; quantitative survey (N = 70)

Dimension	Scaled Score	Mean	Standard Deviation
Organizational Credibility Scale
Culture of Trust and Support	3.55	31.99	6.39
Practices of Inclusivity, Safety, and Wellness	3.53	17.69	3.59
Collaboration and Empowerment	3.55	17.76	3.53
Culturally Responsive Trauma Resilience Scale
Trauma Responsive Services	3.47	34.67	7.22
Impact of Provider Training	3.30	29.71	7.15
Fairness and Respect	3.51	35.06	7.59

Note. Table shows scores by OTR sub-dimension. Scaled scores are calculated by dividing each sub-dimension’s mean by the number of items in the sub-dimension, with a possible range of 1-4 with higher scores indicating a culture more aligned with trauma resilience. The standard deviation is for raw scores.

Table 2.

OTR-PREM dimension results by item; quantitative survey (N = 70)

Dimension item	Disagree	Unsure	Agree
Culture of Trust and Support
I feel safe asking staff questions.	2 (3%)	1 (1.4%)	67 (95.7%)
I feel supported by staff here.	2 (2.8%)	1 (1.4%)	67 (95.7%)
Staff here talk with me in clear and open ways that I can understand.	2 (2.8%)	1 (1.4%)	67 (95.7%)
If I have concerns here, I can talk with staff without it negatively affecting my care.	2 (2.8%)	2 (2.9%)	66 (94.3%)
If I share my concerns with staff, I will be treated with respect, even if they disagree.	2 (2.8%)	1 (1.4%)	67 (95.8%)
If I have a conflict with staff here, I am confident it will be resolved.	2 (2.8%)	1 (1.4%)	67 (95.8%)
I feel physically safe receiving care here.	2 (2.8%)	1 (1.4%)	67 (95.7%)
I feel calm and relaxed when I am here at this organization.	3 (4.3%)	2 (2.9%)	45 (92.9%)
I trust staff here are honest with me.	2 (2.8%)	1 (1.4%)	67 (95.7%)
Practices of Inclusivity, Safety, and Wellness
Staff here often show me they care about my safety.	2 (2.8%)	1 (1.4%)	67 (95.7%)
If I have difficulty traveling, staff here will make sure I still receive the care I need.	2 (2.8%)	3 (4.3%)	65 (92.8%)
My well-being is important to staff here.	2 (2.8%)	2 (2.9%)	66 (94.3%)
Staff support me in making my own decisions.	2 (2.8%)	4 (4.3%)	65 (92.8%)
Staff here treat me as an equal (do not act as though they have power and control over me).	2 (2.8%)	1 (1.4%)	67 (95.7%)
Collaboration and Empowerment
I trust that decisions here are made with my best interest in mind.	2 (2.8%)	1 (1.4%)	67 (95.7%)
Staff here seem to respect each other.	2 (2.8%)	1 (1.4%)	67 (95.7%)
Staff here connect me with care in my community when needed.	2 (2.8%)	2 (2.9%)	66 (94.3%)
Staff in one department can easily refer me to staff in other departments.	2 (2.8%)	3 (4.3%)	65 (94.3%)
Staff here work with me to create shared goals for my care.	2 (2.8%)	1 (1.4%)	67 (95.7%)
Trauma Responsive Services
Staff have asked me if I have experienced trauma.	3 (4.3%)	4 (5.7%)	63 (90.0%)
Staff here routinely asks me if I am safe or need assistance to stay safe.	3 (4.3%)	3 (4.3%)	64 (91.4%)
Staff help me deal with any unfair treatment I have received related to my identity.	2 (2.8%)	4 (5.7%)	66 (91.4%)
I believe staff here serve patients of all races and ethnicities fairly.	2 (2.8%)	1 (1.4%)	67 (94.7%)
Staff here help me understand the effects of trauma or stress and ways to feel safe.	3 (4.3%)	1 (1.4%)	65 (92.9%)
Staff here can connect me to mental health providers who are trained to help stress and trauma.	2 (2.8%)	3 (4.3%)	65 (92.9%)
Staff understand and respect my personal safety needs.	2 (2.8%)	1 (1.4%)	67 (95.7%)
There are staff here who look like me or share a similar identity.	4 (5.8%)	10 (14.3%)	56 (80.0%)
Staff here help me connect with other people who share similar experiences.	3 (4.3%)	8 (11.4%)	59 (84.2%)
When I receive services here, staff do not judge me based on how I live my life.	3 (4.3%)	2 (2.9%)	65 (92.9%)
Impact of Provider Training
Staff here talk with me about how trauma and stress affect my health.	5 (7.1%)	4 (5.7%)	61 (87.2%)
Staff here treat me as though I have the ability to solve problems for myself.	6 (8.5%)	10 (14.3%)	54 (77.1%)
When staff talk with me about my health, they focus on my strengths.	2 (2.8%)	5 (7.1%)	63 (90.0%)
Staff are sensitive to how I have personally experienced challenges in my life.	3 (4.3%)	10 (14.3%)	57 (81.5%)
Staff here share some of their own experiences in ways that are helpful for me.	3 (4.3%)	8 (11.4%)	59 (84.3%)
If I am ever angry or upset, staff here know how to help me calm down.	4 (5.8%)	9 (12.9%)	57 (81.4%)
Staff here set clear boundaries with me.	2 (2.8%)	4 (5.7%)	64 (91.4%)
Materials about stress, trauma, and resilience are visible throughout the organization.	4 (5.8%)	6 (8.6%)	61 (87.2%)
Staff work with me on techniques to overcome negative beliefs.	3 (4.3%)	6 (8.6%)	61 (87.2%)
Fairness and Respect
If I share my beliefs with staff, I feel heard and understood.	2 (2.8%)	2 (2.9%)	66 (94.3%)
Staff here are respectful to my personal beliefs.	2 (2.8%)	2 (2.9%)	66 (94.3%)
Staff here are respectful of my culture and traditions.	2 (2.8%)	3 (4.3%)	64 (91.4%)
I feel safe talking honestly about my needs with staff here.	2 (2.8%)	4 (5.7%)	64 (91.4%)
I am encouraged by staff to share my opinions about the care I receive here.	4 (5.7%)	2 (2.9%)	66 (91.4%)
I am treated fairly here no matter how I identify.	2 (2.8%)	2 (2.9%)	66 (94.3%)
Staff here accept me the way I am.	3 (4.3%)	2 (2.9%)	65 (92.9%)
Staff here use respectful language when referring to me.	3 (4.3%)	2 (2.9%)	55 (92.9%)
Staff here respect my spiritual practices.	2 (2.8%)	2 (2.9%)	66 (94.3%)

Note. Table depicts primary responses on a collapsed five-point Likert scale to facilitate readability, for 70 youth with HIV receiving care from a youth-focused HIV clinic in the Southern United States. Data were collected between July 2024 - March 2025.

Qualitative Interview Results

Organizational Credibility

Culture of Trust and Support (CTS)

Qualitative data indicated respondents consistently emphasized the high quality of care and services provided at the organization, particularly in comparison to other hospitals. Staff were described as genuinely interested in patients’ well-being rather than merely fulfilling job responsibilities. One person stated,

“I was able to open up to them, and I feel like when I opened up to them, I felt like I could trust them.” (Transcript 9; Black heterosexual female, age 29)

Many noted the continuity and professionalism of both clinical and support staff, citing respectful and consistent treatment across visits. Positive experiences extended beyond clinical interactions to include front desk and transportation personnel, who were generally perceived as approachable and engaging. Respondents valued that staff showed genuine concern, often anticipating needs without being prompted. Participant responses were generally positive, with the clinic often described as feeling like home—a place where trust had been cultivated over time and where patients felt truly cared for. The environment was frequently characterized as supportive; respondents described staff as well-prepared, friendly, and capable of putting patients at ease. Many expressed deep trust in their providers, including social workers and psychologists. One person stated,

“I felt very supported, I felt like I wasn’t alone. I felt like I had help.” (Transcript 9, Black heterosexual female, age 29)

Factors contributing to trust-building included low staff turnover, a nonjudgmental approach, and patient privacy protections through required, explicit consent before sharing information. Patients felt safe due to strict security protocols, including regular identification checks and gate-controlled entry. Several highlighted the convenience and accessibility of services such as on-call doctors, medication delivery, and the ability to attend appointments with partners who were also patients. Practical support for patients, including gas reimbursement and childcare provided during appointments, was also appreciated. Digital health tools like the patient portal further enhanced the patient experience by facilitating easy access to information and medications.

Interviews indicated the clinic was seen as having a culture of trust and support. Interview themes suggested staff consistently demonstrated genuine interest in patients’ well-being and provided accessible explanations of health information. One person stated,

“They really seem like they want to help you, they really interacting and getting tuned with what's going on instead of just doing it as a job.” (Transcript 10, Black heterosexual male, age 21).

Many spoke about having a strong sense of trust for clinic staff, which was seen as fostered through respectful, nonjudgmental care, consistent confidentiality practices, and continuity of care. Patients appreciated the clinic’s diligent security measures, consent discussions, welcoming environment, and a broad range of accessible services, including transportation, medication delivery, on-call doctors, and family support. Comfortable non-clinical “flex rooms” and a relaxing common area were also appreciated.

Digital health tools like the patient portal reportedly enhanced convenience, and staff—from front desk to clinicians—were seen as approachable and compassionate. One person described staff as “amazing” and went on to say,

“They’re always nice, always uplifting. Even if something's wrong, you don’t say anything, they’ll somehow figure out that something’s wrong and ask if you’re okay. So it’s a very good staff” (Transcript 2, Black heterosexual male, age 19).

One aberration from the general culture of support related to security guards. One person discussed having less than desirable encounters with a security officer, stating:

“all the security guards – they have been nice, but it’s just one security guard, his mouth is just so smart. I can’t deal with it” (Transcript 5, Black gay male, age 20).

Practices of Inclusivity, Safety, and Wellness

Participants highlighted the clinic’s strong commitment to privacy, emotional safety, inclusivity, and respectful, nonjudgmental care. One person stated,

“They make me feel very safe. When it’s hard sometimes to try to open up and talk to someone, they make you feel very welcome and make you wanna’ just open up and just continually continue to tell them about every little thing.” (Transcript 7, Black gay male, age 29, patient partner).

Staff were praised for protecting confidentiality, providing emotional support beyond medical treatment, and responding appropriately to patient concerns. The presence of social workers and psychologists enhanced feelings of safety. Additional features like transportation and family spaces were appreciated. As relayed by one participant commenting on the continuity and accessibility of care,

“[They] make it really easy for me to receive care there, and transportation, which for me is my biggest obstacle” (Transcript 11, Black gay male, age 21).

In total, respondents emphasized the importance of privacy, emotional safety, and nonjudgmental care in their experiences at the healthcare organization. One patient noted how critical confidentiality was when they first accessed services as a minor and appreciated that staff respected their privacy by not using full names in open spaces and by avoiding scheduling conflicts with other patients with whom they had personal history. Staff were described as respectful, treating all patients equally and responding appropriately to concerns. Examples include reassigning staff when requested and encouraging patients to advocate for preferences during blood draws, with one patient stating that corrective action had been taken when there was an unsatisfactory experience during a blood draw. Patients valued the emotional support provided by social workers and other staff, who not only addressed medical needs but also engaged in personal conversations and helped patients develop action plans for their concerns before leaving the clinic. The overall experience was described as inclusive. A person stated,

“I’m just more comfortable here. Than I ever been anywhere else.” (Transcript 13, Black heterosexual female, age 21)

When prompted to make suggestions for care improvements, only one theme emerged relative to the location of the new building. Two patients stated dissatisfaction with clinic relocation, with one person describing it as requiring more walking (transcript 12, Black gay male, age 21). No other themes emerged among multiple patients, but several patients provided anecdotal suggestions. For example, while transportation services in general were appreciated by patients, one patient requested more advanced notice of appointment scheduling (Transcript 2, Black heterosexual male, age 19). Another patient reported that an insurance company had inadvertently breached their confidentiality when sending a statement home to their family member (Transcript 1, Black bisexual male, age 19). When prompted for any additional trainings that might be helpful for staff, one patient suggested the need for greater sensitivity of staff in uncovering unspoken needs, stating

“…trying to get into […] what the patient's kind of feeling, kind of trying to put themselves in a mindset of what you know, what's not being said, what they don't want to say, how they feel and stuff like that. I say that they need to kind of just train a little bit more on it, or even, you know, try to be more patient, really with […] a little bit more support emotionally […] to being patient with us. This is a lifelong thing for patients.” (Transcript 10; Black heterosexual male, age 21)

Collaboration and Empowerment

Interview results indicated patients saw the environment as highly collaborative with services tailored to individual needs and clinicians who are invested in patient health and wellbeing. One person stated,

“If they need multiple people, they'll call someone to help me…they work together and things like that” (Transcript 13, Black heterosexual female, age 21).

Staff were praised for their collaboration in patient care, responsiveness, education efforts, and support with both medical and nonmedical issues, connecting patients to community resources as needed. Digital communication and multiple feedback options enhanced convenience and engagement, and patients felt their input was often acted upon. A patient expanded on this sentiment by stating,

“I feel like they work very well together. Communication is great. There’s no details left out. As far as outside help and support and things like that, they are 100% on top of it. If you’re not, they will be because they want to have that support. They want you to be able to cope and recognize and be able to go on with living your life with what you’re dealing with” (Transcript 3, Black bisexual male, age 23).

Autonomy was respected through choice in care decisions, including medication, confidentiality, and services utilized. One area for improvement included follow-up support after appointments. Overall, care was experienced as empowering and patient centered.

Respondents described observations of staff supporting each other and working together to address patient needs. Patients appreciated being offered services tailored to their individual circumstances, including counseling, legal support, housing referrals, and financial assistance, at times initiated by staff without specific request from patients. HIV education provided by staff was viewed as empowering, enabling patients to better understand and manage their health and share information with others. Clinicians were described as invested in patient well-being and attentive to preferences, offering choices around medication types, procedures during blood draws, and levels of confidentiality for information shared across providers. While condom use was reported as persistently advocated by clinicians, patients did not report perceived pressure to take other medical care suggestions. Housing and LGBTQ+ resources, and the opportunity to participate in research studies and the youth community advisory board, reportedly demonstrated a commitment to connecting patients to community services. Patients reported regular opportunities to provide formal feedback through multiple channels, including paper surveys, emails, phone calls, texts, and the patient portal. The patient portal also reportedly allowed for convenient communication with providers, often with response times faster than the 48-hour standard cited. Overall, patients described a care environment characterized by respect and empowerment, with a strong emphasis on tailoring care to individual needs and preferences.

Culturally Responsive Trauma Resilience

Trauma Responsive Services

Respondents widely supported the integration of trauma screening into routine care, with varied views on timing, frequency, who should conduct it, and how results should be shared within the clinic. One participant stated,

“I say they should share it because they're the ones trying to help you. They need as much information as possible” (Transcript 10, Black heterosexual male, age 21).

Another shared a similar sentiment, underscoring the potential connection between trauma and HIV care outcomes:

“The trauma that you deal with can have you missing clinic visits or your health visits. The trauma that you deal with can have you so depressed where you don’t wanna take care of your own health. So, I feel like the trauma piece is very important because if you can get past that trauma piece, you can focus more on your health” (Transcript 1, Black bisexual male, age 19).

Participants expressed a strong consensus that trauma screening should be a routine, integrated component of care. Several participants made recommendations regarding how trauma screening could occur. These recommendations centered on maintaining informed consent and patient control over who accesses screening results, with social workers and mental health staff considered the most appropriate screeners. Several participants emphasized the importance of trust, with some preferring screening after rapport is built, while others supported early contact, ideally at intake or the first appointment, as necessary to connect patients to appropriate services as soon as possible. Many advocated for screenings to occur at multiple points—initial visit, periodically (e.g., monthly or annually), and during follow-up medical appointments—given that a patient’s psychological state can change over time. Counseling and trauma-related services were seen as critical, with some advocating for peer support. Overall, TIC was viewed as necessary, with an emphasis on consistent, individualized, and discreet implementation for patients processing multiple sources of trauma. One participant advised,

“I definitely don't think that screening them on their very first visit is a good idea. Because you don't want to make your patient feel questioned. […] You want to create a safe environment for the person before pushing that screening” (Transcript 12, Black gay male, age 21).

Across responses, there was a shared belief that trauma screening should be conducted with informed consent and that results should be disclosed only to specific staff identified by the patient, though some didn’t mind if this was shared with their care team without their knowledge. Privacy and sensitivity were repeatedly highlighted as essential, especially to avoid re-traumatization or triggering interactions. Most felt screening and assessment results could be shared with patient consent, with one patient stating,

“I definitely think that making sure that (the) patient is okay with that information being shared will make them feel safe…only sharing that with that patient's care team. But you want to make sure that that (the) patient knows that’s who its shared (with)” (Transcript 11, Black gay male, age 21).

However, another urged,”…if I’m not harming myself, then you should [not] be telling nobody” (Transcript 12, Black gay male, age 21).

Respondents felt that TIC was compatible with the clinic due to its individualized approach, and though not all viewed it as the highest priority, the availability of trauma-related services (e.g. mental health support, spiritual care) was considered vital for patients coping with chronic illness and/or past trauma.

Some respondents noted that while they had not used onsite counseling or peer support services, they believed these should be universally available, with options offered according to patient readiness. Increased opportunities for self-expression beyond standard surveys, especially for younger patients, was suggested alongside peer support and family counseling. Peer support services especially were recognized as an important resource, with most patients indicating they had not been offered the opportunity to engage with a peer. One person stated,

“Well, no. I haven’t met nobody yet so far. And hopefully if I do, we can share previous experience because I feel like that would be a great conversation. I wouldn’t mind having that conversation with somebody” (Transcript 6, Black gay male, age 18).

Although most participants felt confident in how their trauma was being addressed, one mentioned that counseling access depended on self-advocacy rather than systematic offering. In summary, feedback indicated support for routine, consent-driven, and confidential trauma screening processes delivered by a well-coordinated, trauma-informed care team, and ample opportunities for counseling services.

Impact of Provider Training

Patients generally felt supported at the clinic, valuing trust-building, counseling, and empathetic staff who often anticipated their needs. Patients described their experiences with trauma as challenging but generally felt supported in the clinic, emphasizing the importance of trust-building with providers, who were seen as nurturing and attentive. One person stated:

“All the trauma I talked about has been in my sessions – I mean, it feels good to have somebody to talk to and … let go of the things that are kind of bottled up in your mind […] I feel like [this clinic] has a really well together put team for trauma and for everything like that […] I feel like that they're doing everything that they need to do” (Transcript 1, Black bisexual, age 19).

Counseling services were viewed as empowering, particularly in addressing issues related to racism and homophobia. One person stated,

“just throughout every experience I've had with homophobia and racism, she's [counselor] really helped me center myself and realize that I do have rights, and I do deserve to be treated well in respect to that person as much as anybody else does” (Transcript 11, Black gay male, age 21).

Several emerging areas showed there were mixed responses to the perception of the impact of staff training, including telehealth, after-hour services, and staff attentiveness to emotional needs. One respondent described feeling like staff “need[ed] to kind of just train a little bit more […] or even, you know, try to be more patient, really with […] a little bit more support emotionally…” (Transcript 10, Black heterosexual male, age 21). Participants valued telehealth as a means for providers to maintain contact and check in between appointments.

Staff across roles were praised for their attentiveness and empathy, often intuitively recognizing when patients were struggling and responding proactively without requiring explicit disclosure. Physicians were described as nurturing and consistent in health monitoring, while phlebotomists took care to ensure patient comfort during blood draws. However, one person expressed concern about a challenge encountered to receiving after-hours crisis response services for mental health, stating:

“There was an incident […] and I called the clinic, and I was just telling them, ‘I need to talk, to speak to my social worker, the on-call social worker.’ And they were, ‘Why? What’s going on?’ Well, if it’s 10:00 at night, and I need to speak to a social worker, I would assume that something major is going on. So, they were asking me, ‘Well, for us to transfer you or find you a social worker, we need to know what’s going on.’ So, I was, ‘I’m feeling suicidal […] So, I guess when I explained it to […] my social worker and my psychiatrist, they were like, that wasn’t the protocol and things like that. Someone’s really supposed to stay on the phone with you…” (Transcript 1, Black bisexual, age 19)

Fairness and Respect

Interviews indicated patients viewed the clinic as a culturally diverse and sensitive space, with staff generally respecting personal identities, beliefs, and preferred pronouns, and providing individualized care. One person shared,

“They were very sensitive. They always asked pronouns or religions. Or even before we get to talking about anything like that, they ask just to make sure that I’m not uncomfortable” (Transcript 1, bisexual, age 19).

While some shared that discrimination was addressed when reported, others felt experiences of homophobia or racism were not openly discussed. Although the clinic was generally seen as fostering inclusivity through cultural representation and spiritual support, some patients perceived subtle pressure to conform to certain beliefs. One person stated,

“I will say there’s one thing about [the hospital]: they do not discriminate. Ever since I’ve been going to [the clinic], I have not experienced a moment where they have discriminated against myself or any other patient in the hospital…I’ve seen people of all races at [the hospital]. In the Infection Disease Clinic and throughout the whole hospital itself” (Transcript 5, Black gay male, age 20).

Respondents noted the cultural diversity and versatility of staff, who were seen as generally reflective of patient identities and welcoming regardless of racial or ethnic differences. The clinic’s environment was enhanced by informative cultural decorations and displays, contributing to the perception of an inclusive atmosphere. Patients appreciated staff’s cultural sensitivity, including routine inquiries about pronouns and respect for spiritual and personal beliefs. Personalized treatment plans were valued, often tailored to accommodate individual dietary, religious, and cultural preferences. The availability of the patient portal to access providers and appointment information was also seen as helpful. Staff were described as proactive in addressing discrimination, such as referring patients to the Equal Employment Opportunity Commission when needed. However, some patients reported no explicit discussion of homophobia or racism during care, indicating potential opportunities to integrate into TIC services.

Finally, Table 3 shows a joint display of quantitative and qualitative findings to depict how meta-inferences were drawn from each source. We followed categories set forth by Greene, Caracelli, and Graham (1989), ³⁵ with attention to triangulation or convergence (e.g., when findings generally agreed), complementary (e.g., when one finding helped to elaborate on or clarify the other), development (e.g., when one method informed the other), initiation (e.g., when new perspectives are provided by the other that are contradictory), and expansion (e.g., when one data source extends the understanding or breadth of the inferences drawn by one source).

Table 3.

Joint display of quantitative and qualitative findings of OTR-PREM index, with meta-inference

OTR dimension	Quantitative result	Qualitative result	Meta-inference
Organizational Credibility scale	​	​	​
Culture of Trust and Support	Sub-dimension with one of the highest mean scores (m=3.55) and rates of agreement (93%-96%).	Clinic perceived to have high-quality care, with staff who genuinely care and can be trusted. Patients feel consistently respected. Environment described as feeling like home.	Converging themes relative to perceived trustworthiness, the welcoming nature of the space, sense of professionalism, continuity of care, authenticity of staff, and an emphasis on patient privacy, cultural sensitivity, and autonomy.
Practices of Inclusivity, Safety, and Wellness	Sub-dimension had very similarly high mean scores (m=3.53) and agreement (93%-96%).	Clinic seen as having a strong commitment to privacy, emotional safety, inclusivity, and respectful, nonjudgmental care. Staff praised for protecting confidentiality, providing emotional support beyond medical treatment, and responding appropriately to patient concerns.	Converging themes indicated the culture of trust and support was upheld through clinical practices that promoted safety and inclusivity while providing holistic care.
Collaboration and Empowerment	Sub-dimension with one of the highest mean scores (m=3.55) and rates of agreement (93%-96%)	Environment seen as highly collaborative and respectful, where services are tailored to individual needs and clinicians are invested in patient health and wellbeing.	Converging themes and expansion, with survey results showing strong collaboration and interviews expanding this by indicating mechanisms that promote collaboration, including ease of making/connecting to referrals and fluid service coordination.
Culturally Responsive Trauma Resilience scale
Trauma Responsive Services	Sub-dimension had relatively lower mean scores (m=3.47), with 80%-96% agreement.	Patients expressed support for the integration of trauma screening, assessment, and interventions, as well as a need to increase peer support.	Converging themes showed there was need to enhance trauma screening, assessment, and interventions as well as peer support.
Impact of Provider Training	Sub-dimension had the lowest mean scores (m=3.30), with agreement only 77%-82%, and lowest score for if staff treat patients as though they can solve own problems.	Patients generally felt they could talk with staff about traumatic experiences and would be supported. Two participants made recommendations for suggested changes, with one being enhanced staff training to better respond to patients’ unspoken emotional needs, and the other person recommending enhanced after-hours crisis response.	Data were complementary with partial convergence. Quantitative data suggested lower scores in some areas, with qualitative data largely affirming patients felt supported by their providers, but small instances of change were recommended to better respond to emotional or crisis-response needs.
Fairness and Respect	Sub-dimension scores were more similar to Organizational Credibility scale dimension, with 91%-94% agreement, with one low-performing item: staff share similar identities (at 80% agreement)	Staff were described as overall being culturally responsive (with inclusivity fostered through cultural representation and spiritual support), but there were instances in which patients perceived either a subtle pressure to conform to certain beliefs or stated that while discrimination was addressed when reported, homophobia or racism were not as openly discussed.	Data were complementary in that surveys indicated high scores for high scores for fairness and respect and interviews helped to identify ways the clinic could strive to enhance cultural responsiveness.

Note. Table shows each the performance of each quantitative scale within the Organizational Trauma Resilience – Patient Reported Experience Measure, qualitative themes using these scales and their sub-dimensions to thematically guide coding, and meta-inferences drawn from the two methods in parallel, following mixed methods classifications set forth by Greene, Caracelli, and Graham (1989).

Discussion

Interviews and surveys were conducted to assess patient perspectives about Organizational Trauma Resilience (OTR) prior to implementing trauma-informed care (TIC). Findings indicated the clinic has a culture that is strongly aligned with OTR constructs of trust and support, collaboration and empowerment, and practices of inclusivity, safety, and wellness. Recommendations were provided for how clinic trauma screening, assessment, and intervention approaches might be best adopted. The current study contributes to a growing knowledge base on preferences for the implementation of trauma-informed HIV care. Specifically, most past research has narrowly focused on personnel perceptions, without the inclusion of patient perceptions, and with infrequent attention to the role of cultural responsiveness as part of TIC. ³⁶ To our knowledge, this is the first study that qualitatively assessed patient experiences using the Organizational Trauma-Resilience – Patient Reported Experience Measure (OTR-PREM) framework as well as the first applying a mixed methods design with the OTR-PREM. The high Kappa statistic scores, consistent with the Cronbach alpha measurements for the validated quantitative survey, supports qualitative application of the OTR framework. Finally, findings hold important implications for the study of TIC that relies on evaluation at multiple levels within a system— with both patients and personnel.

The current study provides the first account of the perspective of adolescents with HIV relative to OTR. Thus, findings from the current study present an important first step in understanding patient preferences for trauma-informed services among youth with HIV (YWH) who are disproportionately represented in the HIV epidemic and among those meeting criteria for PTSD. Findings were generally consistent across both surveys and interviews, highlighting the reliability of results and the OTR framework. Both methods revealed similar findings for two dimensions of the Organizational Credibility scale—Culture of Trust and Support and Practices of Inclusivity, Safety, and Wellness—converging themes relative to perceived trustworthiness, the welcoming nature of the space, sense of professionalism, continuity of care, authenticity of staff, and an emphasis on patient privacy, cultural sensitivity, and autonomy. Perceived alignment of OTR culture did not appear from experiences with personnel of different positions, but some minor differences emerged relative to staff roles. For example, social workers were seen as having the longest-standing and deepest relationships with patients, oftentimes throughout their entire time as a patient; the psychologist was seen as the trauma expert; physicians and advanced practice providers were seen as safe and supportive but not key players in trauma disclosures; and ancillary staff played important roles in trust- and rapport-building during initial visits for new patients. Further, the OTR scores for these dimensions were comparable to those from other HIV service organizations or clinics in Tennessee, ²⁵ with higher scores—indicating perceived higher levels of safety, stability, and nurturance—observed for the current clinic across most OTR dimensions. ²⁵

As compared with the other two sub-dimensions of the Organizational Credibility scale, slightly lower appraisals were observed for Collaboration and Empowerment and all dimensions within the Culturally Responsive Trauma Resilience scale (i.e., focusing on equity and fairness and trauma-informed practices). Emerging themes revealed that trauma services were valued and desired by patients, but concern was raised that access to these services sometimes depended on self-advocacy rather than universal availability. Additionally, results from both methods revealed lower appraisals relative to trauma screening practices, which were perceived to be inconsistently delivered (e.g., timing and frequency). Quantitative scores for these sub-dimensions of OTR were consistent with ratings from another study in different sites—Trauma Responsive Services and Impact of Provider Training had the lowest scores for the current sample but were still higher in the current sample compared to other sites. ²⁵

A few findings showed nuanced emphasis by data collection method. Qualitative findings reflected a strong sense of collaboration relative to patient decision-making, and quantitative survey results were relatively consistent (90.6%). Qualitative interviews added that patients generally perceived staff to be representative of them, yet this was one of the lowest appraisals on the quantitative survey. Some of these discrepancies could relate to the larger sample size employed for the surveys, or the patient interviews may have included greater levels of social desirability bias given the one-on-one discussion as compared with self-administration of a survey.

PTSD prevalence was mixed when compared with other studies. We observed prevalence that was slightly lower than that among adults in other HIV care settings in Tennessee measured in similar ways: 37%-47% (depending on the assessment tool) in the current study met criteria for probable PTSD, compared to 63% in adults with HIV in another study, and only 30% in our study met criteria for provisional diagnosis, whereas about half of the adults in the other study received a confirmatory diagnosis, ³⁷ and lower than those reported for acute stress disorder from a pediatric behavioral clinic in Memphis (64%). ³⁸ While we are not aware of any population-level estimates of PTSD prevalence for youth in Tennessee, the current study observed far higher PTSD rates than the prevalence of poor or fair mental health overall among the general population of youth in the state (8%) ³⁹ and among a younger age group of general pediatric samples in the state (2%). ⁴⁰ Two factors likely contributed to the current observed PTSD prevalence in this sample. First, results from two systematic reviews indicated studies using convenience sampling (versus consecutive sampling or randomization) are more likely to produce higher prevalence.^41,42 Second, it is possible that PTSD prevalence is higher in the region given the rates of adverse childhood experiences shown in the region converging with the high rates of HIV burden and social vulnerability. ⁴³

Given the need to assess clinic culture across multiple levels (i.e., among patients and personnel), we compared findings from this study with those from our recent studies conducted with personnel from the same clinic. Results generally were corroborated by other methods of data collection with personnel in the same clinic. Past methods of process mapping and personnel interviews with clinic and ancillary staff agree that the environment is one that fosters a culture of trust, support, and respect for patients. ²⁸ Both patients and personnel characterized the space as collaborative, empathetic, and focused on individualized care. All findings depicted the environment as welcoming, equity-focused, patient-centered, and collaborative, with trustworthy providers who show respect for patients, emphasizing the perceived credibility and positive climate of the clinic. There appears also to be general agreement relative to concrete practices such as screening, assessment, and treatment of trauma, with exception of two notable differences. First, personnel were more likely to discuss operational constraints such as staff burnout, aligning with much of the literature on the impact of providing HIV care ⁴⁴ ; however, these observations were understandably less relevant to patients. Instead, patients were more likely to highlight the need for greater representation among staff and peer support, aligning with results reported in an umbrella review of systematic reviews on TIC. ³⁶ Peer support is a critical need that the current study brought to light. Past research has demonstrated a bi-directional benefit of peer support, as it can both facilitate self-acceptance and combat the caustic nature of illness-related stigma ⁴⁵ while simultaneously promoting empowerment among those providing the peer support. ⁴⁶ These findings have been consistent across global contexts, through many types of studies and data collection methods, and have been associated additionally with improvements in HIV care including linkage to care, retention in care, and viral suppression rates.^47-51 Largely, both patients and personnel interviews revealed a perceived need to prioritize TIC via universal protocols that are part of routine workflows.

Trauma services recommendations for routine clinical care

Although specific findings about the clinic may not be generalized to other clinics, the patient recommendations for trauma screening, assessment, and treatment have strong implications for real world clinic procedures. Primarily, patients expressed that trauma screening and assessment should be offered universally as an ongoing component of care as new experiences emerge for the patient. Patients unanimously wished to receive trauma services, but there was a lack of consensus on timing. Individual readiness was emphasized, with some patients recommending services be provided during the first visit while others felt strongly that providers should build rapport with patients before asking such sensitive questions. Existing rapport was highlighted as an important component of patients reliably reporting accurate information. Additionally, there was a lack of consensus about how often trauma screenings should be re-administered, with some patients suggesting monthly, others annually, and some at any follow-up visit. There was also variation relative to who should do the screenings, with consensus suggesting social workers or mental health providers as administrators.

The overwhelming concern among patients for trauma services related to privacy, consent, and information sharing. Generally, patients emphasized the need for them to control who sees these results on an individualized level, underscoring need for person-centered care, which was stated as a critical component of informed consent processes. Some felt that results should be shared with their direct care team, but the general theme was that result-sharing should be individualized to each patient and discussed up front. These findings relating to privacy and trust mirror those reported in another sample of youth. ³⁹ Other studies discussed need for screening and assessment processes to be tailored to youth ⁵² via “survivor-led guidelines” and done so as part of routine clinical practices.^36,53 Past efforts have developed such survivor-led guidelines via a longitudinal mixed methods study that could be adapted for the setting. ⁵³ Consistent with these guidelines, patients in the current study also voiced that trauma screening should be delivered in a safe way that depends on trusting, non-judgmental relationships in which consent is clear and person-centered. Patients in the current study stressed the importance of having access to support services following screenings and assessments. This was described as access to counseling, family support, or peer services. While patients voiced concern that there was not adequate peer support within the system currently, they expressed need for more opportunities toward self-expression, underscoring the potential for patient openness to provide peer support. Additionally, current findings are consistent with past survivor-led guidelines in that all emphasize the need for discussions around trauma disclosure to be patient-directed, flexible, and collaborative and not driven by one-size-fits-all protocols. The current study builds on these past findings as patient participants described how trauma screenings and assessments could occur in the context of ongoing care among youth. Future efforts to implement such recommendations in other settings should consider adaptations for settings and age groups. Considerations could be made for patients younger than 18 regarding reporting abuse of minors and with consideration of varying developmental needs.

Further, considerations should be made for how the current clinic can integrate greater trauma training for clinic and ancillary staff to enhance emotional support and standardize crisis protocols. Additional clinic and ancillary training could also be provided to ensure that patients are aware that sensitive topics—issues related to racism, homophobia, and stigma—are not only safe to discuss during routine care but are prompted to do so as part of trauma and safety assessments.

Limitations and future research

The current study includes several limitations. First, both data collection methods relied on convenience samples, which could have introduced bias. This bias could reflect perspectives of patients that are not fully representative of the entire clinic sample. However, there were several indicators that the survey sample was representative generally of the clinic patient population, with an observed 90% racial minority and mean age of 21, reflecting the clinic’s overall population. Convenience sampling could have led to the higher prevalence of participants meeting the criteria for probable PTSD. While multi-measure PTSD provisional diagnosis is considered an acceptable approach for self-guided assessments, ⁵⁴ ideally a more reliable approach would include face-to-face clinical interviewing and assessments with a clinician. While patient interview data appeared to reach saturation, the number of patients interviewed was small, only representing about 7% of patients making up the clinic census. It is possible that the patients who opted to participate could have been more likely to hold positive attitudes of the clinic or more likely to feel obligated to say positive things about the clinic. However, patient demographics generally represented those of the clinic census and qualitative findings generally were consistent with quantitative results. Data are based on perceptions and therefore are limited to recall bias as well as social desirability bias. Further, given the cross-sectional and observational nature of this study of a single clinic, findings may not be generalizable to other clinics. For example, patients in other clinics may make different recommendations for trauma screening and treatment, and other clinics or care settings may have less resources to adequately respond to the recommendations made by patients in the current clinic. Despite these limitations, findings are strengthened by the mixed methods approach which aimed to synthesize findings, comparing them vis-à-vis to demonstrate consistencies and differences between the methods.

These findings suggest future interventions should include protocols for universal trauma screening, assessment, and treatment to ensure all patients receive trauma services. Further, results suggest benefit from training protocols for clinic and ancillary staff to realize, recognize, respond, and resist further traumatization among patients, which have been found in other studies to be effective in improving organizational climate, satisfaction among staff and clients, and care retention. ⁵⁵ Future research engaging patients to guide TIC implementation should consider applying the OTR framework, given its excellent reliability and validity across methodological application. Additionally, future research should explore OTR connections on multiple levels in care systems, ²⁵ relative to psychological (e.g., trauma exposures and confirmed PTSD), HIV (e.g., medication adherence, retention in care, and viral suppression), and personnel professional quality of life outcomes (e.g., compassion satisfaction, compassion fatigue, and burnout.^56,57

Conclusion

We conducted a convergent parallel mixed methods study, using interviews and surveys to identify patient perspectives related to Organizational Trauma Resilience (OTR) in a youth-focused HIV clinic in Memphis, Tennessee. Findings indicated the clinic has a culture that is strongly aligned with OTR constructs of trust and support, collaboration and empowerment, and practices of inclusivity, safety, and wellness. Some areas identified for future interventions include provision of trauma responsive services (such as universal trauma screenings) and personnel trauma training. Patient recommendations for trauma services (i.e., screening, assessing, and treating trauma) are among the first of their kind and hold important implications for clinical practice and research on trauma-informed HIV care. Future research will explore connections between OTR and HIV outcomes, including missed healthcare appointments, and if trauma-focused interventions influence appointment adherence.

Appendix.

List of abbreviations

APA

American Psychological Association

CDC

Centers for Disease Control

HIV

Human Immunodeficiency

LGBTQ+

Lesbian, Gay, Bisexual, Transgender, Queer Plus

EHE

Ending the HIV Epidemic

IRB

Institutional Review Board

ITQ

International Trauma Questionnaire

OTR

Organizational Trauma Resilience

OTR-PREM

Organizational Trauma Resilience- Patient Reported Experience Measure

PRAPARE

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences

PTSD

Post-Traumatic Stress Disorder

PWH

People with HIV

SPRINT

Short Post-Traumatic Stress Disorder Rating Interview

TN

Tennessee

TIC

Trauma-informed Care

U.S.

United States

YWH

Youth with HIV.

ORCID iDs

Leslie Lauren Brown https://orcid.org/0000-0002-6778-4984

April Christine Pettit https://orcid.org/0000-0001-8832-0866

Latrice Crystal Pichon https://orcid.org/0000-0002-2035-8267

Megan Leigh Wilkins https://orcid.org/0009-0007-8520-6292

Ethical Considerations

Ethics approval was provided by Meharry Medical College (22-08-1234), with the participating clinic’s IRB ceding to Meharry as the IRB of record.

Consent to Participate

All participants completed a consent to participate.

Data Availability Statement

Data is available upon request.*