COVID-19 Impact on Pain management: Highlighting, Explaining, and Realigning services (CIPHER)

Background: Transgender and gender diverse (TGD) Veterans are a priority population at greater risk of harm following disruptions in chronic pain care, with higher rates of chronic pain conditions and of physical and mental health comorbidities associated with prescription opioid use and overdose risk. Moreover, TGD Veterans avoid medical care due to negative experiences rooted in stigma, reporting "insensitivity, harassment, and violence" and "a general lack of knowledge about transgender patients and care among providers." Significance: Both the higher rates of chronic pain conditions and the increased prevalence of SUD and overdose risk underscore that consistent chronic pain care and close oversight of care plans are essential for TGD Veterans, and interruptions may have dire consequences. The need to better understand and develop strategies to improve chronic pain care for TGD Veterans is critical and urgent to support wellbeing, manage pain, ameliorate discriminatory treatment rooted in provider biases, and prevent opioid-related crises. Innovation and Impact: Identity Development Evaluation and Sharing (IDEAS) is an innovative, evidence- supported methodology in which qualitative data are presented via theatricalized, filmed monologues. Studies have shown that viewing an IDEAS performance significantly reduces stigma beliefs, and literature suggests IDEAS may facilitate translation of qualitative findings into actionable recommendations for optimizing future care because data are presented in deeply contextualized ways - embedded in Veterans' life experiences. Specific Aims: The proposed work will supplement an existing VA-funded study, CIPHER, which focuses on 1) understanding changes in Veterans' chronic low-back pain care after COVID-19 and their associated impacts; and 2) using these data to develop strategies to optimize future delivery of VA pain services. Aim 1 of the proposed work will enhance CIPHER by elucidating chronic pain care experiences of a high priority population, TGD Veterans. In aim 2 of the proposed work we will apply findings from Aim 1 to develop a novel, interactive intervention to support equitable TGD Veteran care, advancing CIPHER's aim of developing short and long-term strategies to optimize equitable delivery of pain management services post-COVID-19. Methodology: In aim 1 we will purposefully sample TGD Veterans from CIPHER's cohort of Veterans with chronic low back pain use ICD-10 Gender Identity Disorder codes. We will conduct narrative interviews to learn about TGD Veterans' chronic pain care experiences prior to and following the onset of the pandemic. We will identify key messages via thematic analysis of interview transcripts, focusing especially on areas for future care optimization. In aim 2 we will apply IDEAS to produce a 25-minute film with professional actors portraying key messages from aim 1 findings. We will share the film with CIPHER stakeholders and primary care providers during a 1-hour meeting in which TGD Veteran panelists join for a 15-minute PI-moderated post-film panel conversation. Stakeholders and providers will complete a pre/post Acceptance and Action Questionnaire - Stigma, which provides a composite score with lower scores indicating reduced enacted stigma. An unadjusted two sample paired t-test will be used to assess the difference in matched pre-post AAQ-S survey scores. To assess whether IDEAS feasibly and acceptably shares qualitative data to facilitate actionable change, we will distribute the Acceptability of Intervention Measure (AIM) and the Feasibility of Intervention Measure (FIM) anonymously via an online survey that will include space for open-ended responses with each item, asking respondents to describe if/how IDEAS facilitates actionable change. We will use explanatory sequential mixed methods to expand quantitative AIM/FIM findings with qualitative feedback. Next steps/Implementation: The proposed work will result in an IDEAS film depicting chronic pain care experiences of TGD Veterans that can be disseminated by CIPHER stakeholders, as well as data on pre/post change in provider stigma and stakeholders' perceptions of IDEAS feasibility and acceptability.