People living with HIV(PLWH) experience high rates of multi-level trauma resulting from interpersonal violence, institutional stigma and provider bias, and the consequences of harmful policies (e.g. HIV criminalization). Experiences of trauma among PLWH are associated with poor health outcomes. This is due, in part, to barriers to engagement in HIV care related to trauma such as medical mistrust and re-traumatization in healthcare settings. It is essential, therefore, that organizations providing HIV services address the role of trauma in the lives of their clients. Trauma informed care (TIC) realizes the prevalence of trauma among clients, recognizes how trauma impacts engagement in care, and responds through system-wide integration of trauma-sensitive strategies to resist re-traumatization of clients (SAMHSA, 2014). Despite the importance of TIC, little is known about the operationalization and implementation of TIC in HIV service organizations (HSOs). This study addresses this gap through an analysis of qualitative evaluation data from 26 HSOs who have undertaken trauma-informed care organizational systems change (TIOSC) projects to answer the following research questions: 1) In what ways do HSOs make organizational and systems-level changes to better align with the principles of TIC? and 2) What are the barriers and facilitators to implementing TIOSC in HSO settings?
The authors are Director of Evaluation, Director of Programs and Center Director of an Intermediary Purveyor Organization (IPO) which has provided funding, capacity building, and implementation coaching to 26 HSOs to plan and implement TIOSC projects. Project evaluation data includes 15 pre/post TIC organizational assessments, 15 open-ended written evaluation reports, 25 in-depth interviews with grantee organizational leaders and field notes from implementation coaching calls and training sessions. Organizational assessments were analyzed using content analysis. Authors used thematic analysis with sensitizing concepts drawn from organizational development theory and equity-centered implementation science to analyze reports, interviews and field notes.
Results demonstrate that TIOSC strategies were operationalized through changes to HSO culture (revised on-boarding procedures, staff training, trauma-informed language norm-setting and changes to decision-making structures); HSO climate (altering the organization’s physical environment, structuring policies and procedure and addressing staff vicarious trauma) and HSO capacity (improving assessment strategies, strengthening service user feedback mechanisms, and increasing community engagement). Equity-centered implementation strategies included the development of community advocacy boards comprised of People living with HIV to guide TIOSC processes and using a racial justice-centered approach to TIC. Facilitators of TIOSC change included leadership buy-in, clear organizational communication networks and strong existing community relationships. Rigid leadership hierarchies and perceived resource constraints were identified as barriers.
Our study identified key strategies for operationalizing and implementing TIOSC, providing clarity and increasing potential uptake of TIOSC among HSO and other health service settings. To strive toward justice by creating trauma informed organizations, it is essential to intervene on HSO climate, culture and capacity as well as equity centered implementation strategies.
Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.