A HYBRID EFFECTIVENESS-IMPLEMENTATION STUDY OF THE PRIDE IN ALL WHO SERVED PROGRAM FOR LGBTQ+ VETERANS

Background: Social and structural stigma related to “Don’t Ask, Don’t Tell” and transgender military ban policies have negatively impacted the more than 1 million LGBTQ+ Veterans that have served in the US military. Experiences of discrimination are linked to disproportionate risks for suicide and, for some, a reluctance to seek medical care at VA facilities. This proposal examines effectiveness and implementation of the Pride in All Who Served (Pride) intervention for LGBTQ+ Veterans. Developed with Veteran input, the Pride intervention is a 10-week health promotion group consistent with National Academy of Medicine’s selective strategies for suicide prevention. Veteran-reported outcomes include: reduced suicidal ideation and internalized stigma and improved protective factors for suicide (e.g., social connection, resilience). Significance: Suicide is the number one cause of death for LGBQ+ Veterans age 18-29 and is ranked 5th for LGBQ+ Veterans of all ages. Transgender Veterans’ risk of suicide is 20 times higher than other Veterans, with as many as one in three attempting suicide in their lifetime. Despite heightened risks, VA’s National Strategy for Preventing Veteran Suicides does not include any solutions tailored specifically to LGBTQ+ Veterans. Effective interventions are urgently needed in clinical settings to reduce these health inequities. Innovation & Impact: Through a partnership with the VA Innovation Ecosystem and VA Central Office partners, Pride groups rapidly spread to 65 VA sites from 2017-2023. This intervention: 1) is the first manualized group tailored for LGBTQ+ Veterans; 2) is not a mental health group and does not require a diagnosis for inclusion; and 3) is supported by evidence-based implementation strategies. Yet important research questions remain about the effectiveness and implementation of this program before enterprise-wide implementation will be supported. This study is the first: 1) to evaluate Pride using a control group; 2) to examine adoption, sustainment, and cost of any LGBTQ+ Veteran intervention in VA; and 3) the first known hybrid type 2 study to use retrospective structured data to examine intervention effectiveness on suicide risk. Specific Aims: Aim 1: Evaluate effectiveness of the Pride group on LGBTQ+ Veteran outcomes and service utilization over time compared to matched LGBTQ+ Veteran controls that did not attend the group. Pride group Veterans will have lower rates of suicidal ideation (primary outcome), lower risk of suicide attempts and deaths, and greater reduction in depression and anxiety scores in the 12-months after baseline than the control group. Pride group Veterans will also have higher rates of preventive care service use and lower use of emergency services. Aim 2. Evaluate site-level variability in implementation progress and sustainment. Aim 3. Conduct a budget impact analysis to determine resources required to implement Pride at national and local levels. Methodology: This 4-year hybrid type 2 effectiveness-implementation study will leverage VA administrative data and a controlled interrupted time series design (Aim 1) followed by a prospective mixed-methods examination of implementation and cost (Aims 2 and 3). A propensity matched control group of LGBTQ+ Veterans will be compared to Veterans that attended Pride between 2017-2023 for 1 year before and after the intervention. Informed by RE-AIM and health-equity implementation frameworks, mixed methods will be used to examine adoption (primary), reach, implementation, and maintenance at newly trained VA sites (N = 30). Qualitative interviews with VA staff will increase understanding at sites that fail to adopt Pride within 6-months and among existing sites with evidence of sustainment (>1 year). Time tracking by the implementation facilitation team and local delivery sites will inform budget impact analyses for future decision-making. Next Steps/Implementation: Partners in the VA Offices of Mental Health and Suicide Prevention, LGBTQ+ Health, and Health Equity -- among others -- have met quarterly as a Pride Steering Committee for the past 3 years. These relationships have resulted in tangible investments and a readiness to support next steps.