Process Mapping to inform implementation of Trauma-Informed Care for youth aged 14–24 with HIV in the Southern United States

Background: Trauma-Informed Care (TIC) is an evidence-based approach for improving health outcomes by providing systematic, trauma- sensitive and -responsive care. Because TIC adoption varies by setting and population, Implementation Science (IS) is particularly well-suited to guide roll-out efforts. Process Mapping (PM) is an IS model for creating shared visual depictions of systems as they are to identify rate-limiting steps of intervention adoption, but guidance on how to apply PM to guide TIC adoption is lacking. Authors of this study aimed to develop a novel method for conducting TIC-focused PM. Methods: A real-life TIC implementation study is presented to show how TIC-focused PM was conducted in the case example of a pediatric HIV clinic in a Southern urban area with a high burden of psychological trauma among youth with HIV. A five-phase PM model was applied to evince clinic standards of care, including Preparation, planning and process identification; Data and information gathering; Map generation; Analysis; and Taking it forward. Practices and conditions from four TIC domains were assessed, including Trauma responsive services; Practices of inclusivity, safety, and wellness; Training and sustaining trauma responsiveness; and Cultural responsiveness. Results: The TIC-focused PM method indicated the case clinic provided limited and non-systematic patient trauma screening, assessment, and interventions; limited efforts to promote professional quality of life and elicit and integrate patient experiences and preferences for care; no ongoing efforts to train and prepare workforce for trauma- sensitive or -responsive care; and no clinic-specific efforts to promote diversity, equity, and inclusion for patients and personnel. Conclusion: Principles and constructs of resilience-focused TIC were synthesized with a five-phase PM model to generate a baseline depiction of TIC in a pediatric HIV clinic. Results will inform the implementation of TIC in the clinic. Future champions may follow the TIC-focused PM model to guide context-tailored TIC adoption.


INTRODUCTION
Populations burdened by high rates of psychological trauma require more culturally sensitive health care services to promote optimum wellness. Trauma refers to lasting effects (social, physical, sexual, mental, or spiritual) of adverse events, such as catastrophes (e.g., natural disasters, motor vehicle accidents), personal violations (e.g., sexual assault, racism), or life-threatening situations in which escape is di cult (e.g., HIV diagnosis, child abuse, extreme poverty with housing or food insecurity; American Psychological Association, 2013). According to the Substance Abuse and Mental Health Services Administration's Treatment Improvement Protocol (TIP) 57, Trauma-Informed Care (TIC) is a multi-level, evidence-based approach for improving health outcomes by preparing care personnel to Realize, Recognize, and Respond to trauma to Resist Re-traumatization (SAMHSA, 2014). Principles guiding TIC include Safety; Trustworthiness and Transparency; Peer Support; Collaboration and Mutuality; Empowerment, Voice, and Choice; and Cultural, Historical, and Gender Issues (SAMHSA, 2014) or Cultural Responsiveness (Brown et al., 2023;Loomis et al., 2018). Resilience-focused TIC is de ned as of Organizational Trauma Resilience (OTR) or the extent to which an organization provides the safe, stable, and nurturing environment needed to promote TIC (Brown et al., 2021). Implementation Science (IS) is well-suited for guiding TIC, but IS has been infrequently applied to TIC adoption (Brown et al., 2021;Han et al. 2021;Piper et al, 2021). Both IS and TIC direct multi-level change efforts as tailored to communities. Community engagement via IS methods offer an apt engine for attuning intervention to context, as is needed to apply the exible principles of TIC. Further, actionized TIC principles foster democratic and collaborative conditions, with community engagement as a primary vehicle for elevating the voices of many who may have been silenced by structural systems in society. By subsequently implementing a community-adapted intervention, intervention components have been in uenced by communities most intimately knowledgeable of a system, which allows implementation activities to be built from leveraged local resources and strengths while tailoring change efforts towards unique gaps and needs.
Process Mapping (PM) is an IS tool for creating shared visual depictions of systems as they are to identify rate-limiting steps of intervention adoption (Antonacci et al., 2021;Wagner, 2019). Experientially, conducting PM can also serve to prepare people in systems as well as implementers for intervention adoption as a byproduct of engaging community members to collectively construct shared understandings of systems and discuss areas that could be enhanced by the intervention. A recent systematic review identi ed a ve-phase PM approach, including Preparation, planning, and process identi cation; Data and information gathering; Process Map Generation; Analysis; and Taking it forward.
This ve-phase approach includes ten quality metrics related to engaging and educating community members (e.g., patients, personnel, etc.), utilizing standardized symbols, validating the nal map, and planning how to build on knowledge gained. However, no guidance could be found on how PM may be conducted as part of TIC implementation. Formative research is needed to develop methods by which PM may be systematically conducted to uniquely guide TIC implementation. To ll this knowledge gap, the current study was conducted to create a systematic method for conducting TIC-focused PM.

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A case example is provided to illustrate how to apply TIC-focused PM. Compared with the general population, persons with HIV (PWH) are exposed to disproportionately more trauma, suffer worse effects, and face unique additional trauma exposures related to diagnosis and serostatus (Sales, Swartzendruber, Phillips, 2016;Friedman et al., 2015), cumulatively contributing to higher rates of Post-Traumatic Stress Disorder (PTSD), disengagement from HIV care, and unsuppressed viremia (Campbell, Raffanti, and Nash, 2019). Extant knowledge suggests these trends are true for PWH of all ages; however, youth with HIV (YWH) experience unique barriers to preventing and addressing trauma and are more likely to endure deleterious neuro-physiological changes, given the trauma burden is occurring during critical years of brain development (Spies et al., 2012).
TIC is as an under-utilized approach with potential to attenuate the syndemic relationship between HIV and trauma. Its implementation has been connected with improvements in patient and provider trauma symptoms and health outcomes (e.g. increases in patient resilience and personnel compassion satisfaction via decreases in burnout; Brown (Piper et al., 2021). Further, extant trauma interventions insu ciently focus on PWH and primarily focus on patient-level change rather than multi-level system change, with very few studies occurring in the U.S. (Sales et al., 2016) or in pediatric HIV care settings.

Case Example Setting
Between December 2021 and March 2022, personnel and patient representatives were recruited from a pediatric HIV clinic in an academic medical institution in an urban area in the Southeastern United States.
The project was designed by a multidisciplinary team, including external investigators of an epidemiologist, physician scientist, psychologists, two social workers, and an implementation science consultation hub, and an internal, clinic-based psychologist. Recruitment was overseen by the two social workers and clinic-based psychologist. This clinic provides medical HIV care for children, adolescents, and young adults living with HIV, primarily those aged 14-24, with documented high rates of psychological trauma (Radcliff et al., 2007). The institution has capacity for and can provide to patients: transportation, food while on campus, research activities, psychosocial assessments and services (e.g., social work, psychology, psychiatry, chaplain), testing/treatment for sexually transmitted infections (STIs), pharmacy, laboratory, and medical care from advanced practice providers, nurses, physicians, medical assistants/nursing care assistant and patient care representatives. This clinic is funded primarily by charitable donations, U.S. Health Resources and Services Administration Ryan White HIV/AIDS Program as well as research-based funding provided by collaborative groups, foundations and pharmaceutical companies, and fee-for-service payments.

Approach
An empirically developed ve-phase PM method was followed, with attention to ten quality metrics (Antonacci et al., 2021). Metrics include attention to clearly identifying service areas, educating personnel on use of PM, engaging patient representatives in PM, gathering information from varying perspectives to inform the construction of a visual PM, iteratively analyzing and updating the map, utilizing standardized PM symbols, validating the map with key stakeholders, and utilizing the map to implement or test areas of improvement in the system. This process entailed iterative community engagement with personnel and patient representatives of the pediatric clinic to uncover the who, what, and how of clinic work ow. The ve phases and action steps taken in the current case example are outlined below, and Table 1 summarizes these methods generally for future researchers and healthcare providers to consider for TICfocused PM. Though PM data may be collected generally as part of program evaluation, activities  Phase 1: Preparation, Planning, and Process Identi cation Preparation for conducting process mapping began with the overall principal investigator (PI) meeting regularly with clinic site-PI [together multiple-PI (mPI)], which led to receiving verbal and written support for the project from the clinic director. The PI held a hospital-wide Grand Rounds presentation to share broadly with the institution housing the clinic about the signi cance, principles, and implementation domains of TIC. Plans to engage the community were presented during developmental stages, as part of an established community advisory group, which comprises researchers, practitioners, people living with HIV, and other community members. The multi-PIs held a kickoff meeting with clinic personnel to share information about the intent of the project. The PI met monthly with an NIH-assigned Implementation Science Hub with the University of Alabama at Birmingham Center for AIDS Research to discuss engagement strategies and plans for PM meetings. Finally, demographics and psychosocial characteristics, as well as appointment no-show rates and HIV outcomes of patients were reviewed by mPIs to assess outcomes and potential service areas of greatest need for change.
PM discussion guides were developed from the TIP 57 to guide discussions around four OTR dimensions, including: 1) Trauma Responsive Services, probing for trauma exposure screening and effects assessments and clinical interventions; 2) Practices of Inclusivity, Safety, and Wellness, probing for efforts to promote professional quality of life and elicit patient experiences and preferences for care; 3) Training and sustaining trauma responsiveness, probing for workforce development efforts; and 4) Cultural Responsiveness, probing for efforts to promote diversity, equity, and inclusion at the clinic-level for patients and personnel. Phase 2: Data and Information Gathering PM discussions were conducted rst through face-to-face site visits and virtual workgroups. Information was recorded through note taking (e.g., visual observations of physical space, interactions with personnel, interpretation of comments and situations by the study team conducting the site visit) and physical documentation of protocols and instruments employed. Virtual meetings additionally included audio recordings for later review. Meals and snacks were provided during face-to-face meetings to incentivize participation.
Patient representatives were engaged as one group, with all being members of a community advisory group with an existing relationship working with HIV providers in the community to guide care for youth. Members of this group were recruited by study team members via verbal and electronic invitations to participate. Because each member of this group had varying familiarity with the work ow of the HIV clinic, the mPIs utilized an experiential activity to generate feedback about work ow. The group was shown a randomized list of clinic services and activities associated with initial and follow-up patient meetings and asked to prioritize the sequential steps for which they would prefer to receive care and discuss how they would like the care administered. Once preferences were identi ed, the group was then shown the clinic's actual current work ow and asked to compare and contrast the two (ideal and actual) systems as a means for eliciting how they might want services to evolve to be more patient-focused or choice-driven.
Introductory personnel meetings focused on eshing out who is responsible for each phase of care and what type of care is provided. See Supplemental Table 1 for a list of topics, questions, and prompts applied during groups. Follow-up groups then focused on gaining a deeper understanding of how care is provided, and providers were engaged in small service group discussions so that each discipline/service area could describe their team approach and typical work ow: this included separate meetings for Patient Registration, Clinic Nurses/ Advanced Practice Providers, physicians, social workers/psychosocial services, research assistants, and pharmacists/pharmacy technicians to speci cally explore shared understandings of standards of care related to the aforementioned OTR domains.

Phase 4: Analysis
To analyze ndings from PM activities, the map was iteratively re ned during and immediately following each work group, to ensure changes were made based on the integration of group member feedback. This was done by reviewing thick notes from discussion meetings and organizing discussion points by the TIP 57 and OTR dimensions. Map drafts were validated or checked for accuracy with a member of each service area as well as the patient representative group.

Phase 5: Taking it Forward
Results from PM discussions were applied to develop an overall plan for moving TIC implementation forward in the case clinic setting. Findings helped to generate a list of action items, an implementation action plan with timelines, identify individuals who might be responsible for actions, and tailor a one-onone interview guide to further explore TIC dimensions that presented as too sensitive to be assessed in group discussion formats, including Culture of Trust and Support, Collaboration and Empowerment, and further probe into Cultural Responsiveness. Final PM ndings were shared clinic-wide with personnel to generate recommendations for long-term actions (e.g., general policies and procedures to be re ned in the clinic) and short-term actions (e.g., best methods for equitably creating a steering committee).

Sample
A total of 47 personnel and eight patient representatives participated in PM discussion groups. About a third of participant engagement occurred in-person in December 2021. The remaining group discussions occurred virtually in 2022. The nal Process Map is depicted in Fig. 1 and shows who is involved in the system, what type of care is provided, and how it is provided.
"Who" is in the pediatric HIV clinic Clinic personnel were responsible for administering care for a patient census of ~ 250 youth with HIV. Providers included physicians, advanced practice providers (APPs; e.g., nurse practitioners and physician assistants), clinic nurses, support staff (e.g., medical assistants, patient care representatives), mental health practitioners (e.g., social workers, psychologist, psychiatrist, music therapist, child life specialist, educational consultant and chaplain), outreach staff, and pharmacy technicians/pharmacists. Finally, there were research assistants and ancillary personnel working in other campus locations but engaging with patients, including security guards, environmental services, transportation administration and drivers, and patient scheduling.
"What" care is provided in the pediatric HIV clinic APPs reported being primary medical care providers for patients, with physicians conducting twice-weekly rounds and leading clinical sta ng discussions in oversight of medical care provided by APPs. Clinic nurses coordinate patient medical care, take histories via health screening assessments and referrals, gather labs, administer medications, and facilitate clinic ow. Medical assistants prepare medical rooms, prepare medical rooms for patients, collect specimens, and take vitals. Patient care representatives register/check-in patients to prepare for visits. Community outreach staff meet patients upon initial diagnosis and link them to clinical care.
All patients were connected with a clinical social worker who provided case management and psychosocial support, including bi-annual psychosocial assessments (e.g., household income, violence in the home, legal proceedings, mental health and substance use history, etc.) and annual Adverse Childhood Experience (ACE) questionnaire screeners (Felitti et al., 2019). Those expressing or showing need for mental health care were referred to the psychologist, who conducted mental health assessments utilizing validated instruments to assess depression and anxiety. Other mental health screeners included a brief depression symptom screener and suicide screener (Posner et al., 2011), administered every six months by clinic nurses. No other routine trauma assessments were conducted with patients. Additionally, individuals needing psychotropic medication management were referred to the psychiatrist who is a consultant holding biweekly afternoon clinics. Research assistants reported regularly conducting validated mental health questionnaires but only for research purposes and results were not integrated into clinical care.
The psychologist was the only mental health provider practicing a trauma-speci c patient treatment modality. However, social workers expressed enthusiastic support for TIC implementation and prior interest in/involvement with it. One had certi cation in trauma intervention and others had training in trauma-sensitive approaches.
When asked about current systems for eliciting/integrating patient and personnel feedback, a hospitalwide satisfaction survey for patients was described but personnel were unsure how the data were utilized or shared. Similarly, hospital-wide employee satisfaction surveys were conducted and shared at larger department-levels, but there were no current practices to elicit clinic personnel satisfaction. Some clinic processes had been amended in response to informal patient verbal feedback (e.g., altering patient screener length), but systematic patient feedback was not routinely gathered or integrated into clinic processes. Personnel and patient representatives suggested the need for clinic administrators to regularly solicit patient feedback (e.g., annual satisfaction surveys) and use it to guide programming. Numerous areas in which patients have authority over their own care were identi ed, including request for/engagement in psychosocial services, medical care engagement, administration of sexually transmitted infection swabs (e.g., self-or nurse-administered), vaccine uptake, and ART initiation.
Regarding workforce development, numerous security guards and nursing administrators were trained every 1.5 years in Crisis Prevention and Intervention to assist when/if a patient becomes escalated behaviorally. When asked about culturally responsive policies and procedures, personnel reported not currently having clinic-speci c policies but that the larger hospital system did have some things in place, including basic annual education about legal protections against discrimination, other bias awareness trainings, and opportunities to participate in group discussions and book clubs on cultural topics. Annual ACE questionnaires are administered within six months of patients initiating care, often during the second visit. This timeframe was set so sensitive questions would be asked after rapport had been built and psychoeducation provided on childhood adversity (i.e., to reduce unreliable results, as patients were perceived to change answers after establishing relationships). Personnel reported questionnaires were inconsistently conducted-due to limited staff resources and patient and personnel discomfort with the questionnaire items-and no identi ed structured protocols for how repeated screenings are conducted or systematic methods for sharing information with clinic personnel. Multiple providers, spanning different service categories, reported conducting informal risk assessments of new patients during initial engagement. These topics included verbal questions about current domestic violence risk and/or suicidal or homicidal ideation. Responses were documented in the patient's medical record. Several personnel, spanning different positions, discussed spending lengthy session times with patients during the rst and second appointments to obtain patient history as part of formal and informal psychosocial assessments. Advanced practice providers and physicians identi ed the need to have improved ease of access to patient responses about trauma exposures, mental health needs, and social determinants of health.
Providers reported engaging in professional development independently, without any clinic-level group trainings being offered speci c to TIC and state that leaders would have to elevate this need to ensure clinic-wide training was feasible (i.e., close the clinic during training times or stagger trainings to keep it open with limited staff). Personnel from several positions expressed desire for the social workers' roles to be expanded beyond primarily case management, into provision of more clinical/therapeutic modalities. A noted bene t to this was that this expansion would be supported as a reimbursable service, which could increase the clinic's ability to provide greater mental health support.
Initiatives to promote professional quality of life were limited and relied on institution-wide efforts such as tangible treats from a care cart (e.g., teas, coffees, snacks, etc.). Personnel reported appreciating this service but found it alone to be insu cient, occurring infrequently, and not speci c to the clinic. Staff burnout and high levels of attrition and turnover were common topics, as was the need for more self-care training and institutional-and clinic-level initiatives to prevent burnout.
The patient representative group generated three recommendations regarding how the clinic might consider integrating patient-centered care, including offering patients a menu of options for the order of services received during rst visits (i.e., when blood is drawn that day), limiting the number of providers patients encounter in the rst visit, and including a navigator or ambassador to remain with the patient on the rst visit to escort them across campus through each appointment during the day.

DISCUSSION
A systematic method for conducting TIC-focused PM has been presented and includes a synthesis of a ve-phase PM model, the TIP 57, and OTR dimensions. Findings from the case clinic are summarized below with comparisons drawn with literature to contextualize ndings. Recommendations are provided in-text and summarized in Table 2 for how champions in the case clinic and other settings may conduct TIC-focused PM and build on results. Actions are organized by OTR dimensions-trauma responsive services; practices of inclusivity, safety, and wellness; training and sustaining trauma responsiveness; and cultural responsiveness. 3) utilize electronic patient-reported outcomes; 4) integrate resilience assessments; and 5) conduct Plan-Do-Study-Act cycles to improve mental health screening practices in an ongoing way.
Formal trauma assessments 1) trauma screening tools should be followed with gold standard assessment tools following positive screens; 2) multilevel resilience assessments should be integrated; and 3) PTSD assessments should include two-step process to con rm diagnoses.

Trauma Responsive Services
In the case clinic, trauma-related screeners were limited to ACE questionnaires and suicide risk screenings, with additional mental health assessments (e.g., depression and anxiety) provided as needed (i.e., not systematically). Strengths of the ACE questionnaire include its parsimony and ability to help identify adversity among youth predictive of future comorbidities (e.g., psychiatric challenges surrounding mental health), so that young patients may be connected with mental health care instrumental in disrupting the formation of comorbidities (Fellitti et al., 2019). Limitations of the ACE questionnaire include its focus on trauma exposures that may not be valid or comprehensive with minority populations in urban settings (Cronholm et al., 2015), an unintentional de cit focus that can occur when not coupled with resilience indicators, and its potential to de ate trauma exposure results because scores are produced by tallying adversities as though each is equally impactful. Hence, ACE questionnaires can be helpful tools when coupled with other instruments.

Limitations
There are several notable limitations to methods applied during PM discussions. Initial discussions were conducted as mixed groups (i.e., not by department and without attention to power differentials between leaders and personnel) that potentially did not reap the most reliable results; discussions rarely brought attention to challenges or perceived problems, which could be attributed to a perceived fear of leadership reprisal. However, during the second phase of discussions, groups were intentionally conducted by job role to better promote safe dialogue spaces. Future TIC-focused PM should organize groups intentionally to reduce power dynamics that may impede transparent discussions. Because of these group discussion limitations, certain topics requiring more con dential settings-including the OTR dimensions of Culture of Trust and Support and Collaboration and Empowerment-were not explored as part of the current work.
Therefore, there may be salient processes that could in uence TIC adoption that were not uncovered during PM activities. Hence, process maps should be followed with one-on-one interview, with ndings synthesized with PM results. Finally, case study ndings only apply to the participating clinic, but the TIC PM methods are hypothesized to be generally applicable for use in other Ryan White-funded clinics in the Southeast U.S.

CONCLUSION
Findings present a systematic method for conducting TIC-focused PM and provide an illustration of how the method was applied within a clinic serving youth with HIV, who are disproportionately affected by trauma. Personnel and patient representatives of the pediatric HIV clinic were engaged for group discussions, following a ve-phase approach, meeting ten quality metrics, to explore the who, what, and how of clinic work ow and validate ndings through member checking. Findings enumerate systematic methods for conducting TIC-focused PM in healthcare settings and mark an expansion of the TIC knowledge base. Recommendations for TIC adoption via implementation science have been provided and may be of use for large numbers of clinics. Recommendations focus attention on multiple levels throughout the clinic, underscoring actions that may be taken to enhance patient and personnel experiences, lling a particular gap in knowledge relative to youth-focused trauma-informed HIV care.
Overall, ndings have the potential to meaningfully inform future TIC implementation. Availability of data and material Data sharing is not applicable to this manuscript as data points were not generated through the presented methods.

Competing interests
There are no competing interests.