A Feasibility Study of a Telehealth Intervention on Health Care Service Utilization among Transgender Women of Color in Washington, DCFunding This research has been facilitated by the services and resources provided by the District of Columbia Center for AIDS Research, an NIH funded program (AI117970), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, FIC, NIGMS, NIDDK, and OAR.
This study was funded by a grant from NIH/NIMHD (5R21MD008624). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
13 February 2018
13 February 2018
03 May 2018 (online)
Background Transgender women of color (TWC) are a medically underserved population who often experience substantial barriers to care. TWC experience high rates of stigma, violence, and entrenched barriers to receiving routine or specialty health services. Novel ways to improve access for TWC are urgently needed. Telehealth is one way to support TWC in overcoming barriers, yet this approach has been largely unexamined. The purpose of this study was to develop a TWC-specific telehealth intervention to increase access to primary and specialty care and then pilot test this intervention in a sample of TWC with at least one structural barrier to care.
Methods Eligible participants were 18 years or older, identified as male sex at birth with a current gender identity of either female or transgender, a member of a racial/ethnic minority, and had experienced at least one study-defined structural barrier to primary or specialty care in the past 6 months. Following a 3-month preintervention phase, participants began a 3-month telehealth intervention which provided secure, remote access to trained, culturally appropriate, peer health consultants (PHCs) via video chat, e-mail, text, or phone. Health care utilization was assessed monthly via computer-assisted self-interview. Outcomes of intention to seek care in the next month and receipt of care in the past month were modeled using generalized estimating equations (GEE).
Results Twenty-five eligible participants were enrolled in the study; a majority were black (96%), older than 25 years (69%), living with human immunodeficiency virus (HIV) (52%), and reported depressive symptomatology (67%). Of the 16 who had at least one pre- and one intervention data collection point, 13 downloaded the mobile video chat application and 7 participated in a qualitative exit interview. The intervention was associated with significantly (p < 0.05) increased odds of intention to seek transgender-specific care (adjusted odds ratio, aOR: 1.76 [95% confidence interval, CI: 1.001–3.08]); participants with depression defined by an elevated Center for Epidemiologic Studies 8-item depression scale (CES-D-8) score were significantly more likely to have intention to seek specialty care (aOR: 10.53 [95% CI: 1.42–77.97]), HIV-specific care (aOR: 2.56 [95% CI: 1.27–5.17]), and mental health care (aOR: 2.56 [95% CI: 1.27–5.17]) during the intervention period. Participants with elevated CES-D-8 scores had significantly greater odds of having sought HIV-specific care (aOR: 2.31 [95% CI: 1.31–4.06]) during the intervention period relative to those with lower scores.
Conclusion These pilot data suggest that telehealth with remote access to PHCs who can provide immediate, culturally competent, nonclinical, education, and referral guidance may be effective in overcoming multiple barriers and improving care utilization outcomes for TWC. Telehealth may be an innovative, low-cost solution to improve health outcomes for populations with multiple barriers to health care services.
Clinical Relevance Statement
Novel ways to improve access to care among transgender women of color are urgently needed. Although telehealth interventions offer new ways to overcome the barriers that transgender women of color often experience, this approach has been previously unexamined among this population. Data from this study suggest that providing immediate remote access to peer health consultants who can nonclinically advise, answer questions, provide health education, and refer patients to appropriate, culturally competent care, may be effective in overcoming multiple barriers and improving care utilization outcomes among transgender women of color.
Protection of Human and Animal Subjects
All study instruments, interventions, and procedures were approved by the George Washington University Institutional Review Board. None of the faculty or staff have financial interest in or conflict with the vendor providing the Digigone application. Use or nonuse of the application had no impact on staff or participant compensation. No animals were used in this study.
* Mr. Watson was an employee of George Washington University during the conduct of the study and preparation of the publication, and is now an employee of Gilead Sciences.
- 1 Ayala DV, Ibañes GE. Barriers to engaging transgender women in HIV observational research. Am J Public Health 2017; 107 (06) e9
- 2 Kussin-Shoptaw AL, Fletcher JB, Reback CJ. Physical and/or sexual abuse is associated with increased psychological and emotional distress among transgender women. LGBT Health 2017; 4 (04) 268-274
- 3 Wood SM, Lee S, Barg FK, Castillo M, Dowshen N. Young transgender women's attitudes toward HIV pre-exposure prophylaxis. J Adolesc Health 2017; 60 (05) 549-555
- 4 Clark H, Babu AS, Wiewel EW, Opoku J, Crepaz N. Diagnosed HIV infection in transgender adults and adolescents: results from the National HIV Surveillance System, 2009-2014. AIDS Behav 2017; 21 (09) 2774-2783
- 5 Eaton LA, Matthews DD, Driffin DD, Bukowski L, Wilson PA, Stall RD. ; POWER Study Team. A multi-US city assessment of awareness and uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among black men and transgender women who have sex with men. Prev Sci 2017; 18 (05) 505-516
- 6 Salazar LF, Crosby RA, Jones J, Kota K, Hill B, Masyn KE. Contextual, experiential, and behavioral risk factors associated with HIV status: a descriptive analysis of transgender women residing in Atlanta, Georgia. Int J STD AIDS 2017; 28 (11) 1059-1066
- 7 Le V, Arayasirikul S, Chen YH, Jin H, Wilson EC. Types of social support and parental acceptance among transfemale youth and their impact on mental health, sexual debut, history of sex work and condomless anal intercourse. J Int AIDS Soc 2016; 19 (03) (Suppl. 02) 20781
- 8 Garofalo R, Kuhns LM, Reisner SL, Mimiaga MJ. Behavioral interventions to prevent HIV transmission and acquisition for transgender women: a critical review. J Acquir Immune Defic Syndr 2016; 72 (Suppl. 03) S220-S225
- 9 Addis S, Davies M, Greene G, Macbride-Stewart S, Shepherd M. The health, social care and housing needs of lesbian, gay, bisexual and transgender older people: a review of the literature. Health Soc Care Community 2009; 17 (06) 647-658
- 10 Brennan J, Kuhns LM, Johnson AK, Belzer M, Wilson EC, Garofalo R. ; Adolescent Medicine Trials Network for HIV/AIDS Interventions. Syndemic theory and HIV-related risk among young transgender women: the role of multiple, co-occurring health problems and social marginalization. Am J Public Health 2012; 102 (09) 1751-1757
- 11 Nuttbrock LA, Hwahng SJ. Ethnicity, sex work, and incident HIV/STI among transgender women in New York City: a three year prospective study. AIDS Behav 2017; 21 (12) 3328-3335
- 12 Eaton LA, Kalichman SC, Price D, Finneran S, Allen A, Maksut J. Stigma and conspiracy beliefs related to pre-exposure prophylaxis (PrEP) and interest in using PrEP among black and white men and transgender women who have sex with men. AIDS Behav 2017; 21 (05) 1236-1246
- 13 Rebchook G, Keatley J, Contreras R. , et al; SPNS Transgender Women of Color Study Group. The transgender women of color initiative: implementing and evaluating innovative interventions to enhance engagement and retention in HIV care. Am J Public Health 2017; 107 (02) 224-229
- 14 Wansom T, Guadamuz TE, Vasan S. Transgender populations and HIV: unique risks, challenges and opportunities. J Virus Erad 2016; 2 (02) 87-93
- 15 District of Columbia Department of Health. HIV/AIDS, Hepatitis, STD, and TB Administration. Annual Epidemiology and Surveillance Report: Data through December 2016. Available at: https://doh.dc.gov/publication/2017-hahsta-annual-reports . Accessed June 28, 2017
- 16 District of Columbia Department of Health. HIV among Transgender Persons in the District of Columbia. HIV/AIDS, Hepatitis, STD, and TB: Data through 2014. Available at: https://doh.dc.gov/sites/default/files/dc/sites/doh/page_content/attachments/HAHSTA%20Transgender%20Supplement%20-%20Final%20format.pdf . Accessed June 12, 2017
- 17 Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inform 2010; 79 (11) 736-771
- 18 Takahashi PY, Hanson GJ, Pecina JL. , et al. A randomized controlled trial of telemonitoring in older adults with multiple chronic conditions: the Tele-ERA study. BMC Health Serv Res 2010; 10: 255
- 19 Gagnon MP, Lamothe L, Hebert M, Chanliau J, Fortin JP. Telehomecare for vulnerable populations: the evaluation of new models of care. Telemed J E Health 2006; 12 (03) 324-331
- 20 Hanlon P, Daines L, Campbell C, McKinstry B, Weller D, Pinnock H. Telehealth interventions to support self-management of long-term conditions: a systematic metareview of diabetes, heart failure, asthma, chronic obstructive pulmonary disease, and cancer. J Med Internet Res 2017; 19 (05) e172
- 21 Trettel A, Eissing L, Augustin M. Telemedicine in dermatology: findings and experiences worldwide - a systematic literature review. J Eur Acad Dermatol Venereol 2017
- 22 Jackson D, Roberts G, Wu ML, Ford R, Doyle C. A systematic review of the effect of telephone, internet or combined support for carers of people living with Alzheimer's, vascular or mixed dementia in the community. Arch Gerontol Geriatr 2016; 66: 218-236
- 23 Bashi N, Karunanithi M, Fatehi F, Ding H, Walters D. Remote monitoring of patients with heart failure: an overview of systematic reviews. J Med Internet Res 2017; 19 (01) e18
- 24 Shea S, Weinstock RS, Teresi JA. , et al; IDEATel Consortium. A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus: 5 year results of the IDEATel study. J Am Med Inform Assoc 2009; 16 (04) 446-456
- 25 Martínez-Alcalá CI, Pliego-Pastrana P, Rosales-Lagarde A, Lopez-Noguerola JS, Molina-Trinidad EM. Information and communication technologies in the care of the elderly: systematic review of applications aimed at patients with dementia and caregivers. JMIR Rehabil Assist Technol 2016; 3 (01) e6
- 26 Magnus M, Edwards E, Dright A. , et al. Development of a Telehealth Intervention to Promote Care-Seeking among Transgender Women of Color in Washington, DC. Presented at the International AIDS Society meeting; Paris, France; July 2017 (Poster number A-854–0213–04282)
- 27 Digigone Remote Communication Solutions. Available at: http://www.digigone.com/ . Accessed March 22, 2018
- 28 Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1 (03) 385-401
- 29 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
- 30 Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 5th ed. Los Angeles, CA: SAGE Publications; 2018
- 31 Magnus M, Sikka N, Cherian T, Lew SQ. Satisfaction and improvements in peritoneal dialysis outcomes associated with telehealth. Appl Clin Inform 2017; 8 (01) 214-225
- 32 Kissinger P, Rice J, Farley T. , et al. Application of computer-assisted interviews to sexual behavior research. Am J Epidemiol 1999; 149 (10) 950-954