Bridging & Innovation: Transgender Community-Engagement to Explore, Plan, and Implement
Adapting the World Café Model
Developed by Junita Brown and David Isaacs in the 1990s, the World Café model (WCM) provides a platform to bring marginalized voices to discussions around particular civic issues, such as expanding access to care, and facilitates community-building and engagement (33,34). Typically, world café events are structured around numerous small-group discussions on curated topics and questions, relevant to specific goals. WCM offers a more horizontal approach to consider health inequities compared to individually-focused and extractive methods such as surveys or even focus groups. This approach was selected to generate dialogue around key topics that centered trans voices. Held in safe, accessible spaces reserved specifically for these events, use of WCM promoted cooperative, practical ways of knowing, and connectedness among communities and stakeholders (35).
In Los Angeles and Chicago, both steering committees curated activities that would amplify the voices of transgender community members among stakeholders, encouraging more effective and collaborative ways to advance transgender health equity. Both steering committees used WCM as a method for organizing and developing a foundation upon which to build both relationships and interventions within and across HIV prevention, healthcare, and social service stakeholders and transgender communities.
Los Angeles: Community Engagement to Inform Intervention Development
Exploration: the Transgender Town Hall. The Town Hall was hosted at a central Los Angeles location on a weekday evening. Complimentary dinner was served and gift cards were provided to all Town Hall participants. Over 40 transgender and gender non-conforming participants attended and contributed to the Town Hall event. Using the World Cafe format, discussions were structured around three areas of concern: (1) primary health care, (2) mental health care, and (3) HIV prevention and treatment. Participants rotated to three different tables for 25 minutes per topic. This rotation afforded each participant the opportunity to provide input across all three domains with different facilitators and peers in each rotation. For each topic, a facilitator used a set of structured probes to prompt conversation in the given subject area, and an observing note-taker recorded participants’ responses and ideas (see Appendix for three sets of probes). Groups were available for both English- and Spanish-speaking participants. At the end of the Town Hall, all participants reconvened as a larger group and were able to share their feedback about the event and suggestions for next steps.
Planning: the Transgender Town Hall findings. After the Town Hall, the steering committee compiled the discussion notes, identified themes, and then developed them into a set of recommendations. Recommendations were organized based on available resources and capacity of the project team and steering committee. For example, regular statewide competency trainings on transgender health for organizations funded by the California Department of Public Health, while an appropriate response to the Town Hall findings, would require immense financial and labor resources and thus were deemed less feasible. This document was distributed to the Town Hall participants and shared with the California HIV/AIDS Research Program, the Center for AIDS Research Health Disparities Core’s funder, with the understanding that the document would not be made public or further shared until an implementation and dissemination plan was developed.
Implementation: Gender-Affirming Care Curriculum for UCLA Health and the UCLA David Geffen School of Medicine. The steering committee determined that based on the recommendations, UCLA was in a unique position to implement change within its health system and school of medicine. They determined that an upstream approach that aimed to promote and enhance the quantity and quality of education for health professionals around transgender health and related issues would be the most effective way to ultimately affect change. This approach is outlined below and is also reflected in the logic model (see Figure 1).
Steering committee representatives from the UCLA team met with a range of faculty and administrators to build a collaboration with the UCLA David Geffen School of Medicine (DGSOM) and its leadership. These conversations helped the team to understand what curricula was already being offered related to transgender health and wellness. The project team also became regular participants in the Clinical Training and Education Workgroup that is part of the UCLA Health System’s LGBTQ Equitable Care Committee. This workgroup is dedicated to the training of UCLA Health staff, residents, fellows, and medical students, and has been an important partnership in advancing the long-term goals of the project.
In 2017 and 2018, as the team ramped up to prepare for the broader DGSOM curriculum intervention, the project team helped to coordinate several brief trainings at UCLA to provide expertise on special topics on transgender health (e.g., transgender patient records in electronic health record systems, mental health disparities). During the 2018 - 2019 academic year, the project team collaborated with UCLA DGSOM to launch an enhanced transgender health session for second-year medical students, building upon existing content of a doctoring class. This session featured a didactic lecture by a subject matter expert, a diverse transgender and non-binary patient panel, and small group discussions between students, faculty, and patient panel members. Evaluation of this updated curriculum demonstrated that it was well-received by students and led to significant changes in knowledge, attitudes, and perceived readiness to work with transgender patients. This session was delivered again to the next two second-year student cohorts during the following two academic years (2019 - 2020 and 2020 - 2021). Due to COVID-19, the 2020 - 2021 session and all of its components were provided to students virtually by Zoom. Over the course of these three academic years, over 500 medical students participated in the enhanced transgender health session.
Currently, the project team continues to work closely with UCLA DGSOM and its faculty as it rolls out a more thorough and school-wide curriculum redesign. The new curriculum is being rolled out in phases and includes additional LGBTQ health content, including over ten hours of class time dedicated to these topics during the first year of medical school alone. The project team has also been critical in the development, implementation, and evaluation of a pilot elective option for students that focuses exclusively on LGBTQ health and direct experience with LGBTQ patients.
Chicago: the Trans Accountability Project
Exploration: Two Community Conversations & Listening Sessions. In the first year, TAP steering committee hosted two Community Conversations, also known as listening sessions for the stakeholders who attended. Sixty-three community members and ten stakeholders attended the events while nine facilitators from the community and nine notetakers from stakeholder organizations assisted TAP in hosting the events. TAP integrated human-centered design principles into WCM as a framework to curate up to nine sets of four small-group activities (see Figure 1) and a collective “report-back” discussion that followed the activities. All materials were translated into Spanish, and one table at the first event was conducted in Spanish for two participants.
Planning based on findings. Based on TAP’s analyses of the data, five insights were generated (36). After much discussion, the steering committee determined that employment would be the domain through which to focus intervention development for years 2 and 3. One element of the intervention would consist of a more downstream approach to improve and expand job-seeking and retention skills of Black and Latina transgender women. The other element would target stakeholders and a more upstream approach to expand employment opportunities and working environments for Black and Latina transgender women. At the same time each partner organization had its own particular employment services that were enhanced by TAP funding.
The COVID-19 pivot. Year two of TAP consisted of setbacks in the development of the intervention due to onset of global COVID-19 pandemic. The steering committee began year two with the development of an employment intervention logic model (see Figure 2) and a scan of local employment interventions accessible to Black and Latina transgender women. With the pandemic, however, partner organizations shifted the majority of programming from in-person to virtual formats in order to minimize staff and client exposure, expand access to COVID-19 testing, and also to ensure services continued to reach community members during mandated closures of community spaces.
Implementation: the TAP Employment Program and stakeholder engagement. In year three, the TAP Steering Committee completed the design of the employment intervention and launched the pilot. The pilot consisted of eight, two-hour monthly modules with a corresponding monthly speaker series; in total, there were 16 Zoom sessions on eight employment-focused topics. In the first month’s module, a visioning activity was conducted with participants to discuss their dream jobs. The first speaker was an elder and leader in Chicago trans communities who had been conducting HIV prevention for over 30 years. She also talked about what her work had been like during COVID-19 and how she maintained accessible HIV testing. In month seven, participants focused on job applications and engaged in mock interviews.
With limited recruitment efforts, five participants ranging in age, race and ethnicity, transition status (i.e., various combinations of legal, social, and medical transition) as well as geographic locations, enrolled and have attended the pilot virtually. The TAP steering committee members typically attended each module, contributing to the activities and discussions, as well as the speaker series. These sustained group meetings between participants and steering committee members, plus speakers from the community, help create a supportive network for the participants in terms of finding and retaining employment. Partner organizations also provided additional employment services supported by TAP resources to community members not enrolled in the program.
Beyond the employment pilot, stakeholders are periodically engaged to prioritize collectively any organizational, local, and state policies that may help transform employment or healthcare barriers into facilitators. For example, TAP steering committee members and stakeholders participate in ongoing workgroups to change policies and advance state legislation around background checks, name changes, as well as the decriminalization of sex work.
Inner and Outer Settings: Organizational Capacities and Funding Mechanisms
The organizations and institutions supporting these efforts varied greatly in terms of capacities to address transgender structural vulnerability. As such, the larger the institution, the less focused the structural competencies may be on transgender health inequities and, further, the smaller the organization, the less able to commit sustained staffing to the intervention development or implementation. In Chicago, for example, the vastly different sizes, locations, and mission and values of the partner organizations posed some challenges to consistent and sustainable participation on the TAP steering committee and the pilot intervention.
Los Angeles inner and outer settings. Initial funding for the Los Angeles Town Hall event was provided by the Tawani Foundation and the California HIV/AIDS Research Program through the UCLA Center for AIDS Research Health Disparities Core. Additional supplementary funding was provided by the UCLA AIDS Institute in order to implement the recommendations derived from data and analyses generated at the Los Angeles Transgender Town Hall.
Chicago inner and outer settings. The TAP steering committee formed as a result of a grant award to address structural racism in Chicago in order to expand access to HIV prevention and care. TAP member organizations had proposed to improve access to HIV prevention and care for Black and Latina Transgender Women using the steering committee model as the core driver to intervene at multiple levels - group, organizational, community, and structural. However, one organization took the lead in the proposal development and submission, and, when funded, the TAP steering committee had less than 12 weeks to establish trusting interpersonal and organizational relationships and to plan and host two community conversations and stakeholder listening sessions.