Volume 21, Issue 3 , Pages 240-255, May 2010
A Community-Based Program Evaluation of Community Competency Trainings
Article Outline
Transgender and gender-nonconforming individuals encounter a multitude of barriers to accessing clinically and culturally competent health care. One strategy to increase the quality and competence of care delivery is workplace trainings. This study describes a community-based program for the evaluation of this type of training. Using a mixed-methods approach, the research team assessed the effectiveness of three competency trainings administered by a local nonprofit organization in the Northwest United States. Quantitative data indicated a significant shift in self-assessed knowledge associated with completion of the training. Qualitative data confirmed this result and revealed a number of important themes about the effect of the trainings on providers and their ability to implement knowledge and skills in practice. Clinical considerations are proposed for providers who seek similar trainings and who aim to increase clinical and cultural competency in delivering care to transgender and gender-nonconforming patients and clients.
Key words: community-based program evaluation, cultural competency, gender-nonconforming patients, quality of care, training, transgender
Despite serious gaps in data collection efforts (Mayer et al., 2008, Sell and Becker, 2001), evidence has shown an association between health disparities and membership in lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities (Dean et al., 2001, Gay and Lesbian Medical Association, 2001). Of these groups, transgender people are likely to experience the worst disparities (National Coalition for LGBT Health, 2004, Xavier et al., 2005).
Health professional curricula have in large part failed to incorporate content about provision of health care to LGBTQ communities (Corliss et al., 2007, Tesar and Rovi, 1998). As a result, national and community-based LGBTQ organizations have attempted to fill gaps in education, delivery of care, and policy where clinical education and practice have fallen short (Mayer et al., 2008). A variety of community health organizations have attempted to address this gap by presenting formal and informal cultural competency training sessions to health professionals in the workplace (Lurie, 2009).
LGBTQ communities have established innovative and high-quality models of preventive, primary, and specialty care in LGBTQ communities (Callen-Lorde Community Health Center, 2009, Howard Brown Health Center, 2009), but competencies in LGBTQ health are not broadly integrated in health care provision in general. Although this state of affairs has allowed for some degree of community expertise to shape training sessions, it has also placed the onus of instruction outside of the context of formal health professional education.
Transgender and gender-nonconforming people are a marginalized group even within LGBTQ communities, and transgender-specific concerns are often sidelined in activism and advocacy (Currah and Minter, 2000, Darke and Cope, 2002). At an institutional level, local, state, and federal data collection agencies have failed to collect specific health-related data about transgender people. Small-scale studies have shown HIV incidence rates of up to 40% in urban male-to-female communities (Clements-Nolle et al., 2001, Nemoto et al., 2004), representing a serious gap in research and prevention efforts.
Because employment discrimination, unemployment, and underemployment are serious issues among transgender individuals (International Conference on Transgender Law and Employment Policy, 1997), transgender women particularly are often overrepresented in survival sex work. Housing access is also an area of vulnerability, and transgender and gender-nonconforming individuals are often particularly affected by gender-segregated shelter policies that do not allow transgender individuals to stay in shelters that house the gender with which they identify (Mottet & Ohle, 2006). Among other issues, these have an enormous effect on health outcomes for transgender and gender-nonconforming communities. Within all LGBTQ communities, existing health disparities along lines of race, socioeconomic status, age, geographical location, and other factors already affect health status. Disparities related to sexual orientation and gender identity exist across LGBTQ communities but have the most profound effect on those already experiencing marginalization.
In 1999, the American Public Health Association issued a statement concluding that health care providers, in large part because of discrimination and lack of training or knowledge, are generally unaware of the health needs of transgender people. The statement asserted that transgender individuals are not provided with adequate health information or health care. It also discussed the failure on the part of research institutions to conduct research on trans-specific issues and to include transgender individuals in research studies (American Public Health Association, 1999).
Inequities in health care for transgender individuals can be observed as taking place on a number of levels. These are evident across a spectrum ranging from individual interactions with health care staff and providers to institutionalized policy. Many transgender people have difficulties accessing transgender-specific and/or transition-specific care because many public and private insurance companies specifically exclude gender-related treatments from coverage (Israel and Tarver, 2003, Minter and Daley, 2003). Cases have been reported of transgender and gender-nonconforming individuals being denied insurance coverage for routine and nongender-related treatments on the basis of their transgender status (Minter & Daley, 2003). Some individual providers, acting on their own accord, have denied routine treatment to individual patients based on their transgender identities (Davis, 2001, Feinberg, 2001, Howell, 1998).
Clinical primary and specialty care guidelines for transgender and gender-nonconforming individuals exist, but they are not generally integrated into general health care practice. Currently, these guidelines are changing and improving and increasingly include the input of transgender individuals in the development process. These guidelines may serve as benchmarks; however, there are questions as to whether providers are aware of the guidelines and have the information needed to serve the health care needs of this population (Goldberg & Lindenberg, 2006).
One strategy for increasing providers' knowledge, skills, and awareness of care guidelines and delivery of competent care to transgender and gender-nonconforming individuals is to offer cultural competency training sessions. The goal of these trainings is to increase the clinical and cultural competence of providers in delivering care to these individuals. Cultural competence, according to Cross, Bazron, Dennis, and Isaacs (1989), refers to the following:
[A] system of care that acknowledges and incorporates—at all levels—the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally unique needs. (p. 1)
Cultural competence addresses the ways in which patients may have different needs, preferences, or expectations of the clinical interaction based on sociocultural memberships and the capacity of providers to negotiate these needs and their own preferred approaches to provision of care.
Clinical competence is based on medical and clinical knowledge and refers to a provider's ability to understand and deliver appropriate clinical care to patients with particular health needs and risks, including knowledge of recommendations, guidelines, or standards of care. A provider may be capable of providing care that is clinically competent but not culturally competent. However, the practice of culturally competent care incorporates clinical competence.
Cultural competency training sessions have been increasingly incorporated into clinical training since the mid 1990s as a tool to increase quality health care provision. Cultural competence has also been integrated into medical and health professional education curricula. Nevertheless, there is a dearth of evidence-based information about the effectiveness of such training sessions on changing clinical behavior. In addition, the concept of cultural competence has decreased in scope over time; initially, it targeted the entire system of care; more recently, it has come to focus primarily on the clinical encounter (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003). Of training sessions that have undergone evaluation, results that show effectiveness have been mixed. However, in spite of these limitations, evaluation data have suggested significant improvements in skills, knowledge, behavior, and attitudes after training (Beach et al., 2005, Kardong-Edgren et al., 2005). Notably, a recent study of a lesbian, gay, bisexual, transgender (LGBT) health curriculum showed a significant change in knowledge and beliefs about LGBT individuals among second-year medical students at the University of California at San Francisco, including an increase in awareness that sexual orientation and gender identity are clinically relevant (Kelley, Chou, Dibble, & Robertson, 2008). Cultural competency training sessions generally take one of three approaches and focus either on knowledge, attitude, or skills. Of these areas, skills-based training sessions seem to be the most effective because these “acknowledge heterogeneity within cultural groups and teach…how to apply knowledge of sociocultural issues at the individual level” (Kripalani, Bussey-Jones, Katz, & Genao, 2006, p. 1117).
Many scholars who have studied transgender health care have recommended and emphasized the need for clinical and staff training to improve provider-patient relationships and increase use of care (Bockting et al., 2004, Kenagy, 2005, Lombardi, 2001). In one of the few studies conducted on transgender patient satisfaction with health care services, a significant correlation was reported between levels of satisfaction and patients' perception of the therapists' expertise in transgender health (Rachlin, 2002).
This community-based study evaluated three clinical competency and cultural competency training sessions administered by a local nonprofit health agency in the northwest United States. Community Competency Trainings (CCTs) served as a way to educate providers about specific strategies to increase quality of care for transgender individuals. The curriculum included information about existing guidelines and standards of care as well as basic anecdotal and clinical evidence about the needs of transgender patients. The organization regularly administered CCTs to health care and social service providers in the northwest. The training sessions aimed to increase clinical and cultural competence in providers who deliver care to transgender patients. The objective of this study was to determine whether these training sessions were effective in increasing the clinical and cultural competence of health care providers in delivering care to transgender patients.
The study used a mixed methods approach to gauge the effectiveness of the CCTs. The quantitative section of the study sought to answer the following research question: Are CCTs associated with an improvement in self-assessed knowledge about clinical and cultural competence with regard to the provision of care to transgender individuals? The change in self-assessed knowledge was measured using a pre- and post-training survey.
The qualitative section of the study sought to understand in more depth what knowledge was gained through participating in the CCT. Research questions included the following:
Methods
Study Participants
Study participants were health care or social service providers including health educators. Inclusion criteria required that providers (a) were involved in direct provision of health or social service care or health education, (b) attended the entire CCT, and (c) completed both the pre- and posttraining surveys. Administrators of agencies, organizations, and clinics learned about the CCT program through word of mouth or by reading about them on the parent agency's Web site. Participants in this research were employed by or associated with three different organizations that enrolled in CCTs. Each CCT was attended by a different group of providers. A total of 68 individuals completed the CCTs.
Participants in the first training, which lasted 6 hours, were public school district employees and included school counselors, prevention/intervention specialists, and health educators. Participants in the second training, which lasted 2 hours, were employees of several large nonprofit clinics affiliated with a national organization. This group was composed largely of licensed practical nurses. Also present were medical assistants, health educators, and nurse practitioners (NPs). The last training, which was lasted 1 hour, included participants from a university-based clinic and consisted of physicians, NPs, and other types of direct care providers.
Approach
This study used a community-based participatory research (CBPR) approach. CBPR is a research approach that engages community members equitably as research partners who contribute valuable and specialized knowledge to the research process. According to Israel, Schulz, Parker, and Becker (1998), in CBPR, “partners contribute their expertise to enhance understanding of a given phenomenon and to integrate the knowledge gained with action to benefit the community involved” (p. 173).
The study was conducted in collaboration with a community research team (CRT) composed of 4 individuals. CRT members were drawn from community networks and participated on a voluntary basis. Three members were transgender individuals, and the fourth was a queer and genderqueer-identified physical therapist. The CRT met monthly over the course of the study and was involved in developing data collection instruments, interpreting data, and generating suggestions for strengthening the training. They did not receive financial compensation for their work, although each was given a grocery gift certificate.
CBPR occurs on a continuum (Minkler, 2005). This study incorporated several aspects of community-engaged research, including collaborative work and analysis with community members. The knowledge gained was intended to shape and improve strategies to increase the clinical and cultural competence of providers to deliver care to transgender and gender-nonconforming patients.
Design
This study used a preexperimental design: a one-group pre- and posttest impact evaluation (Grembowski, 2001). We used a mixed-methods (i.e., both quantitative and qualitative) approach to evaluation, including a pre-post test survey and qualitative follow-up interviews with a subsample. A mixed-methods approach was selected for several reasons. The quantitative data collection instrument used for this evaluation had not been validated, which increased the need for qualitative information to confirm results. The qualitative portion added detail and a depth of understanding to the quantitative results, enabling evaluation results to suggest more robust and comprehensive recommendations with regard to program evaluation. Because few comparable trainings are offered to providers on this topic, there was limited potential for comparison or control groups. Without the ability to conduct a quasi-experimental or experimental program design, inclusion of a qualitative component was particularly important to validate results.
Community Competency Trainings
The CCTs generally covered concepts about LGBTQ health but focused mainly on health care delivery in transgender and gender-nonconforming communities. The duration of training sessions ranged from 1 to 6 hours. The CCTs consisted of three main sections, all of which were delivered in a single session to health care providers. The concepts covered in the first two sections were largely the same in all CCTs, and the third section was somewhat tailored to the clinical specialty or work environment of CCT participants. The training session was mainly knowledge-focused but incorporated some skills-based elements. The formats used to teach these sections varied depending on the amount of time allotted for the training session, as did the degree of depth to which each concept was covered. Table 1 summarizes the main sections and concepts discussed in the CCTs.
Table 1. Summary Table of Community Competency Trainings Curricula
| Sectiona | Concepts/Topics Covered |
|---|---|
| General terminology and background informationb | • Common terms and language • Background about clinical needs |
| Differences between sex, gender, and sexual orientation | • Explanation of differences between terms • Reasons that sexual orientation and gender identity are often grouped together • Strategic reasons to draw parallels/distinctions |
| Information pertaining to clinical provision of care (tailored to specialty/focus of CCT participants)b | • Existing health needs and clinical guidelines • Gaps in research • Barriers to accessing and utilizing health care • Information tailored to clinical discipline or workplace of CCT participants |
aAll sections were delivered in audiovisual lecture format. |
bSections in 6-hour training included interactive discussion and exercises. |
Training sessions were presented by the agency's health education and outreach coordinator (hereafter “trainer”), who is also a transgender man. Participating clinics, agencies, or organizations set expectations with regard to attendance. Providers were generally encouraged but not required to attend. The trainer copresented along with a youth panel presenter for one training session and copresented along with a transgender health care provider (a naturopath) in another training session. He presented alone at the other training session.
Procedures
The principal investigator (PI) and first author accompanied the agency's trainer to each of the three training sessions and was introduced by the trainer before each session as an evaluator. The PI described the project, informed providers about the nature and purpose of the research, and emphasized that participation was optional. The PI also explained that participants were free to take part in either or both components of the quantitative and qualitative research study.
An informed consent form was provided with the pretraining survey to document participants' willingness to participate in the survey portion of the study. This consent form was returned with the completed pretraining survey. At the interviews, participants were presented with a separate informed consent form that described the study and their role as participants. These forms were signed and returned before the interview was conducted. The University of Washington Institutional Review Board for the Protection of Human Subjects reviewed and approved study procedures.
At the beginning of the training, participants received a folder that contained a posttraining survey and a response card to indicate interest in participating in the qualitative interview process. Completed pretraining surveys were collected before the initiation of training. Posttraining surveys and interview interest cards were collected immediately after the training.
Participants who filled out response cards were contacted by telephone within 2 weeks after the training. Again, they were informed that their participation was not required. However, if they agreed to participate, a meeting was scheduled for the interview at a location of their choosing.
Quantitative Survey
To the our knowledge, no existing validated surveys have been developed or published that measure providers' self-assessed knowledge about cultural or clinical competence in delivery of care to transgender and gender-nonconforming communities. We (two of the four members of the CRT and both members of the PI's advisory committee) adapted a validated survey that measured cultural competence in an agency setting: the Cultural Competence Self-Assessment Questionnaire (CCSAQ; Mason, 1995). The researchers used three subscales of the CCSAQ to assess changes in self-assessed knowledge about clinical and cultural competence in delivery of care to transgender and gender-nonconforming individuals. The original intent of the instrument was to measure cultural competence among providers who served people of color. Items were adapted to incorporate issues related to transgender and gender-nonconforming communities and provision of care to patients who are members of these communities. The 4-item subscales included (a) knowledge of community, (b) service delivery and practice, and (c) resources and linkages.
One of the problems with the CCSAQ is its failure to capture information about providers' communication styles and self-assessed bias in clinical interaction. For this reason, we developed one additional 4-item subscale using the American Association of Medical Colleges' (2005) Tools for Assessing Cultural Competency Trainings guidelines. We titled the fourth subscale behavior consciousness and the instrument Clinical and Cultural Competence in Transgender Health Provision: Self-Assessment.
All items used a 5-point Likert scale with one reverse-scored item. For overall cultural competence scores, numerical values corresponding to all Likert-scale responses were averaged at baseline and posttraining, and the difference between the means was calculated. Lower scores indicated a higher degree of clinical and cultural competence regarding provision of care to transgender individuals. Therefore, a negative difference (posttraining mean minus pretraining mean) indicated improvement in self-assessed knowledge around clinical and cultural competence from pre- to posttraining. For greater simplicity in analysis, signs were reversed ([pretraining mean] − [post-training mean] = [overall score]) to obtain a positive value for the overall score. The larger the value, the greater the difference in respondents' self-assessed knowledge scores from pre- to posttraining.
The pretraining survey included a set of demographic items to obtain information about the participant's patient population, workplace, and location of work (i.e., rural, urban, or suburban). Demographic questions also assessed the participant's age, race/ethnicity, gender, and sexual orientation.
Qualitative Interview
The qualitative component of the study used a semistructured open-ended interview format. The interview guide was developed in collaboration with the CRT. Interview data were analyzed to illuminate providers' experiences of the training, to discern remaining questions, and to discover ways that providers implemented training-based knowledge. For the qualitative component, the investigator conducted nine qualitative semistructured interviews with participants from each of the three CCTs.
The interview guide contained eight questions, the majority of which included associated probes. The questions asked participants about (a) their experiences and memories of the training, (b) how providers interacted with transgender and gender-nonconforming individuals in their practices in general and after the training, and (c) other trainings that participants had previously attended. Participants were also asked about questions remaining for them after the training.
Data Analysis
SPSS (Statistical Package for the Social Sciences) software, version 11, was used to analyze quantitative data. Cronbach's alpha coefficient was used to assess internal consistency reliability for each subscale and the total scale. The difference between means from pre- and posttraining was tested using a paired t test to determine whether they were significantly different from zero at a .05 level of significance.
Interviews were digitally recorded and professionally transcribed. Identifying information was eliminated from transcripts. Interview recordings were subsequently destroyed.
Researchers took a grounded theory approach (Strauss & Corbin, 1990) and used a combination of a priori codes derived from the research questions and open coding that emerged from data analysis. ATLAS.ti version 5.0 software was used for coding and managing data.
CRT members read summaries instead of interview transcripts. The CRT generated a list of themes that included those of the training that worked particularly well and suggestions for strengthening the training. Using information from this discussion and concepts covered in the interview guide, we formulated a codebook that included the following thematic categories:
Primary codes specific to the training included (a) content, (b) length, (c) trainers, (d) style of delivery, and (e) posttraining action.
Results
Survey Results
A total of 68 training attendees were eligible for the study based on the eligibility criteria. Of those, 55 people returned usable survey pairs for a response rate of 81%. Four incomplete surveys were excluded. Of the four survey pairs that were incomplete, one failed to complete a pretraining survey, one failed to complete a posttraining survey, and one finished the pretraining survey after the conclusion of the training. The fourth survey was considered incomplete because the respondent answered strongly agree to every item on the posttraining survey, including the reverse-scored item. The remainder of the participants (n = 9) did not complete surveys. Demographic characteristics of survey participants are shown in Table 2.
Table 2. Survey Sample Demographic Characteristics (N = 55)
| Demographic Characteristic | n | % |
|---|---|---|
| Race/ethnicity | ||
 African American or Black | 1 | 1.82 |
| American Indian/Native American/First Nation | 0 | 0.00 |
| Asian American or Asian Pacific Islander | 1 | 1.82 |
| Latino/a or Hispanic | 2 | 3.64 |
| White/Caucasian | 48 | 87.27 |
| Mixed race/biraciala | 2 | 3.63 |
| Not reported | 1 | 1.82 |
| Gender | ||
| Woman | 48 | 87.27 |
| Man | 6 | 10.91 |
| Transgender/transsexual woman | 1 | 1.82 |
| Transgender/transsexual man | 0 | 0.00 |
| Genderqueer | 0 | 0.00 |
| Sexuality | ||
| Heterosexual or straight | 46 | 83.64 |
| Bisexual | 1 | 1.82 |
| Lesbian | 4 | 7.27 |
| Gay | 0 | 0.00 |
| Queer | 1 | 1.82 |
| Other | 1 | 1.82 |
| Not reported | 2 | 3.63 |
| Age | ||
| 21-29 | 10 | 18.18 |
| 30-39 | 7 | 12.73 |
| 40-49 | 13 | 23.64 |
| 50-59 | 21 | 38.18 |
| 60-69 | 2 | 3.63 |
| 70+ | 1 | 1.82 |
| Not reported | 1 | 1.82 |
| Type of workplace | ||
| Community health clinic/nonprofit | 31 | 56.36 |
| State or local government agency | 5 | 9.09 |
| University hospital | 0 | 0.00 |
| Community hospital | 1 | 1.82 |
| Other | 18 | 32.73 |
aOne respondent marked three categories: Latino/a, White/Caucasian, and mixed race/biracial, which was coded as mixed race/biracial. |
Cronbach's alphas were high for the pretraining (α = .86) and posttraining (α = .87) total scale cultural competence scores. For the four pre- and posttraining 4-item subscales, Cronbach's alpha varied from moderately low to moderately high (see Table 3). It is noteworthy that the behavior consciousness subscale, adapted from a different source, had the highest internal consistency reliability estimates.
Table 3. Cultural Competence Subscale Reliability Coefficients
| Subscale | Pretraining Alpha Coefficient | Posttraining Alpha Coefficient |
|---|---|---|
| Knowledge of community | .73 | .54 |
| Service delivery and practice | .45 | .53 |
| Resources and linkages | .68 | .65 |
| Behavior consciousness | .74 | .79 |
Table 4 presents the pre- and posttraining mean scores for the four subscales and total cultural competence scale. Using paired t tests, there were significant differences between pre- and posttraining scores in all areas. For the knowledge of community subscale, t(degrees of freedom [df]) = 6.61(54) with SD .53. For service delivery and practice, t(df) = 6.28(54) and SD = .52. For the last two subscales, resources and linkages, t(df) = 10.37(54) and SD = .57, and behavior and consciousness, t(df) = 8.31(54) and SD = .66. Overall, t(df) = 11.10(54) and SD = .41. These results indicated that the CCTs were associated with improvements in self-assessed knowledge about clinical and cultural competence with regard to the provision of care to transgender individuals.
Table 4. Pre- and Posttraining Cultural Competence Subscale and Total Scale Scores
| Subscale | Pretraining M | Post-Training M | Difference in Mean Scores (Change) | SD | t (df) |
|---|---|---|---|---|---|
| Knowledge of community | 2.26 | 1.79 | .47∗ | .53 | 6.61 (54) |
| Service delivery and practice | 2.11 | 1.67 | .44∗ | .52 | 6.28 (54) |
| Resources and linkages | 2.47 | 1.67 | .80∗ | .57 | 10.37 (54) |
| Behavior consciousness | 2.42 | 1.68 | .74∗ | .66 | 8.31 (54) |
| Total scale | 2.31 | 1.70 | .61∗ | .41 | 11.10 (54) |
∗p < .05. |
Interview Results
Qualitative interviews with providers who participated in the training elicited a number of distinct themes about the training, including perceived strengths and gaps. The interviews also elicited themes about providers' needs with regard to implementing skills and knowledge gained in the training.
TrainingQualitative data revealed interview participants' perceptions about aspects of the training that resonated for them or that were particularly helpful, and aspects that they thought could be strengthened or that would have improved their experiences of the training. Qualitative data indicated that some themes arose regardless of training length and format. All participants, for example, emphasized the importance of medical and clinical information and terminology. With longer trainings, participants tended to focus more on complex concepts in the training, such as using community resources and having contact with individuals from transgender and gender-nonconforming communities. All participants also discussed the barriers they experienced in implementing quality care for transgender and gender-nonconforming patients, regardless of the training duration.
Interview participants thought that the resources provided by the training were valuable both in their continued education about transgender and gender-nonconforming communities and health needs and in helping to build their own resource networks to which they could refer transgender or gender-nonconforming patients. Participants in the longer trainings (2- and 6-hour duration) placed more importance on resources than did those in the shorter training. This result was likely because resources were discussed in more detail during the longer trainings, and the participants had more opportunity to consider ways in which they might more broadly utilize community resources. Although none of the participants specifically mentioned cultivating ongoing partnerships, several commented on the importance of sharing information and making links with other providers and support services in the community. When asked about how to foster a supportive environment for transgender and gender-nonconforming patients in the workplace, one participant responded that “sharing resources and sharing ideas and experiences” was central. Another participant commented, “Part of my responsibility is making appropriate referrals and resources in the community. Thus, learning about resources was another powerful part of the training.”
All but one interview participant emphasized the importance of terminology, definitions, or shared language offered in the training to discuss transgender identity. One participant mentioned the need to “[know] we were speaking the same language.” Learning about terminology was described as central to participants' abilities to understand the distinction between sexual orientation and gender identity. In light of the fact that this was a primary stated objective of the training, this was a particularly important result. Participants in general thought that learning terminology was a means for them to clarify and delineate concepts that were previously confusing and to establish a degree of consensus about language.
“Speaking the same language” was described as an important aspect of learning about terminology, but when asked to describe terms in their own words, interview participants revealed that they held vastly different understandings of the terms that were covered in the training. This result was true across all of the trainings, regardless of length. Although some interview participants offered definitions that were close to terms offered in the training, four participants offered definitions that were simply inaccurate. For example, one interview participant thought that “transgender” referred only to people who desired or pursued gender-related surgeries or hormone treatment, despite the trainer's explicit statement that many transgender individuals never seek these therapies or may seek one without the other. When asked to explain further, the participant revealed that she thought the term transgender would not include a person who “identifies as female…[when that person is] male…has male genitalia.” This notion is not only in direct conflict with the definition of transgender offered in the training, but it would also almost certainly pose serious problems in the context of a clinical encounter. A person's surgical status is a very imprecise metric with which to evaluate transgender identity. Most transgender individuals do not undergo gender-related surgeries, either because they do not view the procedures as integral to their transition or identity or because they are not economically feasible. Many do not seek hormone treatment for similar reasons (Spade, 2009). In attempting to discern a patient's transgender identity based on surgical status or use of hormones, a clinician would likely exclude a large number of transgender patients and would also likely damage the trust of transgender patients by incorrectly assuming them to be nontransgender.
All participants discussed the need for medical or clinical information, but only two participants (one physician and one NP) mentioned this information as the most important or memorable aspect of the training. Participants were eager to learn what one participant described as “the technical information, the medical how-to” of learning about what medical examinations the transgender or gender-nonconforming individuals, particularly those who have undergone surgery or hormone treatment, required. However, despite the references made to guidelines for care during the training session, most interview participants seemed to want to gain this information through discussion and in-person instruction instead of through guidelines. One participant commented as follows:
Things like physical care for routine physical exams I think is extremely important because that's something that you wouldn't necessarily have the information [for] unless someone told you what you should be doing and what you should be thinking, and…if you missed something in someone's care that could be crucial.
This comment showed that participants wanted access not only to concrete aspects of care but also to guidance in their conceptual approach, in “what you should be thinking.”
Interview participants also valued learning about financial barriers to transgender and gender-nonconforming individuals who pursue hormone treatment or surgeries as a result of exclusions imposed by public and private health insurance plans. Some expressed surprise about some of the difficulties associated with accessing these types of medical care. One participant stated, “[The information about insurance issues] was horrifying. I had no idea. And that just scares me, really. I don't know what steps you can take to help make that better, but that's just absurd to me.” Participants also expressed alarm at the barriers that transgender and gender-nonconforming people often encounter in attempting to access primary health care. One participant said, “A person's a person, no matter what parts they have…if they're sick, they need help.… That's terrifying [that they wouldn't be able to access care].” Providers from all the trainings had a strong response to learning about these barriers, and although they were not sure how to direct this response, it seemed to be a driving force toward seeking opportunities for action and advocacy.
All but two participants discussed the presence of a transgender trainer as beneficial. Participants expressed that this was important for them to prepare for contact with a transgender or gender-nonconforming individual in a clinical context. One participant mentioned that the “experiences that were shared were really rich.” Another participant said, “[People] need to be able to hear some experiences of trans people so they're not like, ‘Oh my God, [whispering] is that person trans?’ during the whole [clinical encounter] and they're not listening.” Another participant reported that the trainer's disclosure of his transgender identity was the most memorable part of the training and commented as follows:
It was great [when the trainer]…identified himself as FTM [female-to-male]…. I kind of wish he would have done that more toward the beginning. … I think that's what I took away from it most was … oh, this is who we're talking about, this is who he's presenting about is people like himself and people similar to him, as opposed to this image of who would be walking through the door.
Notably, the trainer was a White, passing transgender man. The assumption on the part of the participant that “this is who we're talking about” could present serious problems in a clinical interaction with a nonpassing or non-White transgender individual.
Overall, participants were very satisfied with the trainings. All participants expressed that they learned new information, and all mentioned considering or implementing new ideas into their practices based on what they learned from the trainings.
Despite interview participants' enthusiasm about hearing from a person who had personally encountered some of the issues that were discussed in the training, data showed that they also perceived that some experiences from a broader cross-section of transgender and gender-nonconforming communities were missing. One of the probes associated with a question about interaction with transgender patients was, “Tell me a bit about how you deal with patients who may be transgender and also people of color or racial/ethnic minorities.” Three participants responded that they interacted no differently with these individuals. The remaining six individuals either discussed specific strategies or stated that they did not know how or did not think that they were specifically prepared to deal with transgender people of color. One provider commented that she did not necessarily think that the training prepared her to deliver culturally competent care to patients who were non-White. She said, “[The training] didn't seem to have an ethnic line to it, or a cultural line. It more just dealt with transgender. It didn't occur to me during the training.… I didn't even factor in cultural differences.” A number of other participants echoed this perceived lack of preparation or information about delivery of care to transgender people of color. This theme was informative in two ways. First, it revealed that some participants thought that delivering care to people of color who are transgender was more complex or specialized than delivering care to White transgender individuals. Second, it revealed that some participants seemed to implicitly assume that the discussion of “transgender individuals” in the training referred primarily to White transgender individuals.
In addition to the identified gaps in content, a number of participants commented on the ways in which the structure of the training might be changed to make it stronger or more effective. As mentioned previously, duration of CCTs ranged from 1 to 6 hours. Of the 6 participants who commented about the length of the training, 4 were satisfied with the training duration and 2 thought that it was too short. Both participants who thought the training would have benefited from additional time were enrolled in the 1-hour training. Two hours was the minimum length of training with which participants were satisfied. One participant who took the 6-hour training would have preferred more time. Of all the providers, physicians and NPs received the shortest training (i.e., 1 hour). This group also estimated that they saw the greatest number of transgender patients. However as one participant in this group noted, “that's our standard CME [continuing medical education] time, unfortunately.”
Also, with regard to training structure, interview participants thought that the training would have benefited from a more interactive format. This result was consistent with a metaanalysis of CME outcome literature conducted by Mansouri and Lockyer (2007), who reported that effect size of provider knowledge, performance, and outcomes were larger with interactive interventions and CME offerings that used multiple methods. A variety of strategies for interaction were suggested by participants, including demonstrations, discussions, games, anonymously submitted questions, and more personal stories from the presenter or other people. One participant commented as follows:
You know, what would have been good is some sort of role play, or something where [the trainer] was either the patient or the provider.… I mean, it's hard to role-play one person to represent a whole population of people, but just in general, like these are the problems… and how do you communicate with this person, and how—I don't know, and how not to, I guess.
Participants who participated in the shorter trainings acknowledged that the time limits imposed on the training made it difficult to incorporate an interactive component with the clinical information presented.
All 9 participants mentioned at least one concrete step that they had taken or were planning to take in their practice as a result of the training. Some participants mentioned that they became stronger advocates for transgender patients and were able to effect change in policies or infrastructures and to adopt guidelines or standards of care for patient interactions. Participants named these as “next steps” independently; none had been specifically suggested or assigned in the context of the training. Participants perceived that their commitments might have been even stronger had they been concretely guided, encouraged, or assisted.
Provider settings and needsThemes of the training itself were of primary concern in evaluating the CCT. However, motivations and abilities of the participants to implement knowledge into practice were discussed as being influenced by perceptions of their work setting in terms of geographical location, types of practice, institutional values, and characteristics of colleagues. Also important were providers' ideas about what professional support needs pertaining to infrastructure or policy would be beneficial to them in their practice. These themes illuminated some of the challenges and opportunities that participants discussed with regard to providing better care to transgender individuals in their workplaces.
A number of interview participants perceived that many of their colleagues did not find it necessary to build clinical and cultural competence to deliver care to transgender and gender-nonconforming patients. Participants described social, religious, and political barriers that resulted in staff not receiving the training required to build these competencies. Also discussed were the ways in which both colleagues and leaders within the clinic, organization, or agency shaped the culture of their workplaces. However, participants noted that individuals in leadership positions had greater power to affect system-wide change. One participant commented, “People in positions of power and leadership…have the ability to make significant systemic changes.”
Some participants thought the barriers to their ability to provide clinically and culturally competent care for transgender and gender-nonconforming patients were linked to limitations in institutional policy and infrastructure, including physical and operational aspects of the facilities in which they practiced that negatively affected quality of care for these patients. Among the barriers were a computer charting system that did not include a means to record a gender other than “male” or “female,” limitations of policy and protocol with regard to gender-segregated jail cell placement, and lack of support and options for transgender students with regard to gender-segregated spaces such as locker rooms and restrooms.
The participants described the need for institutional support in overcoming these barriers, and many were skeptical about the likelihood of institutional leaders being concerned about these issues. Thus, little is known about how to implement knowledge regarding cultural competence with regard to transgender and gender-nonconforming care, and gaining insight into providers' perceived barriers to implementation was valuable.
Discussion
On the basis of the results regarding differences in self-assessed knowledge from baseline to posttraining, the CCT was reported to be effective with respect to self-assessed knowledge. The mean change was about three fifths of a point, which is fairly small. This limited effect size may have been because of the relatively brief length of the training, the fact that it was only offered as a single session, or the relatively low degree of interaction with participants. Selection bias may also have played a role.
Regardless of the magnitude of change, quantitative and qualitative data clearly showed that participants benefitted from the training. The measurable improvement in knowledge mirrored results from other evaluations of cultural competency trainings. Given that the literature to date has primarily addressed training sessions that have focused on cultural competence with respect to race, ethnicity, language, and immigrant or refugee status, it is noteworthy that a training session that focused on transgender issues was also reported to be effective.
In general, participants reported that they learned useful and important information, and they perceived that they were able to translate this knowledge into practice. Given the profound health disparities experienced by transgender and gender-nonconforming communities, this translation of knowledge into practice is very important and warrants further research. Relationships between increased self-assessed knowledge and patient satisfaction also need to be explored in greater detail. In particular, it will be informative in the future to investigate the ways in which training sessions are linked to providers' decisions to advocate at a level beyond the clinical interaction on the part of transgender and gender-nonconforming communities.
One of the major problems of the training was the unintended consequence of providers leaving with a reduced sense of what it means to be transgender or gender-nonconforming. This was likely in part because of the knowledge-based focus of the training. Offering simple definitions or a singular narrative or experience may have inadvertently narrowed the perceptions of participants and may have minimized or masked the wide range of gender expressions, identities, and experiences within transgender and gender-nonconforming communities. A focus on health care barriers instead of terms and experiences (Spade, 2009) may provide greater opportunity to broaden perceptions and expectations of providers.
The training session was successful in teaching practical skills regarding medical and clinical care and in teaching about opportunities to utilize community resources. The CCT might have benefited from translating some of these instructional strategies to skill-building exercises to help providers better understand how to elicit information about patients' identities, preferred language, health needs, and particular challenges. Shifting from a knowledge-based training to a skills-based training may help to mitigate the danger of participants leaving with a reductive rather than an expansive notion of transgender and gender-nonconforming communities (Beach et al., 2005, Kripalani et al., 2006).
In part, knowledge-based training sessions may be broadly offered in response to providers' desire and enthusiasm for concrete knowledge (e.g., terminology), as was reflected in the qualitative results of this study. LGBTQ agencies and organizations have likely developed curricula to meet this perceived need on the part of providers. This need for knowledge may be driving the popularity of knowledge-based rather than skills-based training, thus reducing the possibility for providers to access the most effective types of training sessions.
The goal of training, as articulated in the literature that has addressed needs in transgender and gender-nonconforming communities, is to improve patient-provider relationships and increase utilization of care. Based on the results of this study, it is likely that providers gained a number of important and useful skills regarding medical and clinical care. They also gained a degree of familiarity with some aspects of transgender and gender-nonconforming communities. But, as was illustrated in the qualitative results, the training session may have also led providers to deliver care in a way that could actually damage trust with some transgender or gender-nonconforming individuals. More research is needed to identify which strategies work best to maximize trust-building, competence, and patient satisfaction and minimize harm. However, moving in a direction toward skills-based rather than knowledge-based, training is likely to improve learning outcomes.
An important new result from this study was that participants took it upon themselves after the training session to plan or implement knowledge, and many times this action step reflected a desire to advocate for an improvement in the context or setting or care in their workplaces for transgender and gender-nonconforming patients. This result provided confirmatory evidence with regard to the training's effectiveness, because implementation of knowledge is key to increasing clinical and cultural competence in care. However, the result also pointed to an important area for further study about what leads providers to advocate for their patients on a structural level rather than to simply increase the quality of clinical care on an individual basis.
In addition, more research is needed regarding the barriers to delivering culturally competent care to transgender and gender-nonconforming individuals. A number of interview participants discussed these barriers without being prompted, and institutional and social factors were clearly important perceived obstacles to improving quality of care.
Study Limitations
A major limitation of the study was the number of trainings that were evaluated. Additional trainings would have provided more data, allowing for increased power in quantitative analysis. In addition, although the trainings did not vary a great deal in the concepts covered, they varied significantly in structure and in the amount of detail in which various concepts were discussed. Three training sessions did not allow for a thorough analysis of differences between various types of training structures and effectiveness. However, qualitative data were valuable in confirming results from the small sample, thus strengthening the quantitative results.
The instrument that was adapted was initially intended to measure cultural competence in agencies that serve people of color. Although there are some similarities to issues present in transgender and gender-nonconforming communities, there are also issues that are unique about cultural competence with regard to race and ethnicity as well as gender identity. Given the dearth of instruments available to measure effectiveness of cultural competency training sessions in general, it was necessary to adapt this instrument despite the clear differences in context. It will be useful in the future for researchers to develop and validate a cultural competence instrument specific to transgender and gender-nonconforming communities.
A large majority of training session participants were White and female. Most participants were heterosexual, and most were between the ages of 40 and 59 years. The sample demographics did not characterize all health care providers in the northwest region. It would be beneficial for future studies to gather information from a more representative sample and to further examine some of the reasons for the marked imbalance reflected in this study.
As an external evaluator engaging in community-based participatory research, the PI was working on an abbreviated timeline and was thus limited in the ability to cultivate longstanding relationships with community partners. Community-based participatory research is characterized by equitable and sustained relationships with community members and community-based organizations, and an evaluation of similar training sessions would ideally include community partners in a more formative role in research and implementation of changes.
Conclusions
Training sessions may be an excellent resource to increase clinical and cultural competence among clinical and support staff. As study results showed, providers responded positively to training, and it is likely that the increase in self-assessed knowledge will affect the quality of health care. Ideally, formal education will at some point adequately address the need for basic familiarity and competence with transgender and gender-nonconforming patients. Until such time, providers must take the initiative to foster a supportive clinical environment for transgender and gender-nonconforming individuals. Doing so will likely improve the quality of care more broadly across the patient population. However, this outcome is even more probable if training sessions take an approach that allows for broadly applicable skills-building.
Some critics of cultural competency training sessions have argued that to eliminate health disparities, it is not the individual behavior of providers that must be attended to, but rather, as King (1996) noted, the “institutional patterns” of discrimination that are “legitimated and promulgated…within the medical health complex” (p. 30). In qualitative interviews, participants discussed the institutional structures and forces that played a powerful role in their ability to deliver clinically and culturally competent care to transgender patients. Based on these data, clinical conduct is a combination of individual choices and behavior and institutional policies or expectations. Therefore, for cultural competency training sessions to be effective, it is important to consider both individual and institutional aspects of care delivery.
Despite limited time and a variety of other constraints, CCTs resulted in tangible change in knowledge among health care providers. The needs of transgender and gender-nonconforming patients seem to be moving into the broader consciousness of providers, and trainings are one formal means of education to help providers grow and evolve in the area of transgender and gender-nonconforming culture and care.
Disclosures
The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest.
Acknowledgments
The authors would like to thank the other members of the community research team, Dean Jackson and Breanna Anderson, for their work and participation.
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Christoph Hanssmann MPH, CHES, is a health educator in Seattle, Washington.
Darius Morrison and Ellery Russian, PT, are community research team members in Seattle.
Sharyne Shiu-Thornton, PhD, is executive director, International District Housing Alliance, Seattle.
Deborah Bowen, PhD, is professor and chair, Department of Social and Behavioral Sciences, Boston University School of Public Health, Boston, Massachusetts.
PII: S1055-3290(09)00235-0
doi:10.1016/j.jana.2009.12.007
© 2010 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.
Volume 21, Issue 3 , Pages 240-255, May 2010