A pre/post quasi-experimental study of provider stigma and Veteran experiences surrounding a narrative “IDEAS” intervention to promote positive clinical encounters

A pre/post quasi-experimental study of provider stigma and Veteran experiences surrounding a narrative “IDEAS” intervention to promote positive clinical encounters | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A pre/post quasi-experimental study of provider stigma and Veteran experiences surrounding a narrative “IDEAS” intervention to promote positive clinical encounters Sally Wasmuth, Johnna Belkiewitz, Francis Pike, Mio Ueki, Dawn Bravata This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6156715/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background : Transgender and gender diverse (TGD) Veterans face significant health disparities, often exacerbated by provider stigma. The US Department of Veterans Affairs (VA) prioritizes research to improve care for TGD Veterans. This study evaluates the feasibility and acceptability of the IDEAS - a film-based intervention designed to reduce provider stigma and improve clinical encounters for TGD Veterans. Methods : A pre/post quasi-experimental design was used to assess the impact of the IDEAS intervention on provider stigma and TGD Veteran experiences. The study involved primary care and mental health providers from a Midwestern VA Medical Center and TGD Veterans who had appointments within six months before and after the intervention. Providers completed the Acceptability of Intervention Measure (AIM) and Feasibility of Intervention Measure (FIM) post-IDEAS, and the Acceptance and Action Questionnaire – Stigma (AAQ-S) pre and post-intervention. TGD Veterans completed the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Item Set (CAHPS-CC) and an author-created survey. Results : The IDEAS intervention was found to be both acceptable and feasible, with average AIM and FIM scores above 4. Provider stigma, as measured by the AAQ-S, decreased significantly post-intervention (p<0.01). TGD Veterans reported improved perceptions of provider cultural competence and affirming care post-intervention, with notable improvements in communication, trust, and respect. Conclusions : The IDEAS intervention shows promise in reducing provider stigma and enhancing the healthcare experiences of TGD Veterans. Further research is needed to explore the long-term impact of such interventions on TGD Veteran health outcomes and to refine assessment tools for capturing nuanced patient experiences. Introduction The US Department of Veterans Affairs (VA) has considered transgender adults to be a high priority population and has placed value on research that supports exemplary care for transgender and gender diverse (TGD) Veterans. Nearly 20% of the adult transgender population has served in the United States Military. 1 Regardless of political context, development and implementation of evidence-based, stigma-reduction interventions are urgent and critical to support the health and safety of TGD Veterans. 2 Forty percent of TGD Veterans attempt suicide and many report disaffirming healthcare experiences deterring them from seeking needed medical services. 3 – 4 TGD Veterans are significantly more likely to have greater psychiatric and medical comorbidities compared to non-TGD Veterans. 2 , 5 Stigma exacerbates health disparities, as it can dissuade TGD Veterans from revealing their identities to healthcare providers who may not ask about gender identity, limiting delivery of affirming, comprehensive care. 6 By contrast, affirming policies can decrease harm – for instance, employment non-discrimination protections for TGD Veterans has been associated with a 26% decreased likelihood of mood disorders and 43% decreased likelihood of self-harm. 7 VA research has examined health services utilization and barriers and facilitators to care from the perspectives of TGD Veterans and VA healthcare providers, but implementation of Veteran-informed, evidence-based interventions to improve affirming TGD patient care is needed particularly for providers who may not otherwise seek out this type of training. 8 – 9 IDEAS is an evidence-supported film-based intervention developed by occupational therapists to reduce provider stigma. 10 IDEAS involves conducting narrative interviews with populations who have been harmed by provider stigma and creating a short film depicting experiences of healthcare inequity. The current study examined the impact and implementation of an IDEAS film that was created based on interviews with TGD Veterans about their healthcare experiences. We played the film for two VA provider populations – primary care and mental health. The film screenings took place during regularly scheduled virtual team meetings and were followed by a reflective conversation between providers and TGD Veterans we invited to join the meeting. Purpose The purpose of this study was to measure the feasibility and acceptability of IDEAS implementation in VA mental health and primary care, and to assess change in pre/post provider stigma. A secondary aim of this project was to explore the methodological feasibility of examining IDEAS’ impact on TGD Veterans. We accomplished this by conducting satisfaction surveys with TGD Veterans that assessed the cultural competence and cultural humility of their providers prior to and following their providers’ engagement with the IDEAS training. Methods Design We used a hybrid type 2 design 11 to examine IDEAS implementation acceptability, feasibility, and effectiveness (decreased provider stigma). We also tested the feasibility of a nested data collection methodology for assessing whether IDEAS implementation with providers impacted care from TGD patients’ perspectives. Participants This study was reviewed by the Indiana University institutional review board and given exempt status – study number 16200. Participants included 1) primary care providers and mental health providers from a Midwestern VA Medical Center who attended the IDEAS training; and 2) TGD Veterans within the Midwestern state where IDEAS was offered who had a primary care or mental health appointment within six months prior to and following IDEAS implementation with providers. All participants underwent the informed consent process. Measures and Data Collection Provider Data Collection We collected data from primary care and mental health providers because these two services were highly utilized by the TGD Veteran population. 12 – 13 Acceptability is defined as “the perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory,” and feasibility is “the extent to which a new treatment, or an innovation, can be successfully used or carried out within a given agency or setting”. 14 To measure acceptability and feasibility of IDEAS, we administered the Acceptability of Intervention Measure (AIM) and the Feasibility of Intervention Measure 14 to providers immediately after the IDEAS training. The AIM and the FIM demonstrate good substantive and discriminant content validity, structural validity, scale reliability, test-retest reliability, and sensitivity to change. 15 Questions are rated on a 5-point Likert scale from strongly disagree to strongly agree. We defined implementation success as an average score of at least 4 out of 5 (‘agree’) on both measures. Table 1 depicts the questions that comprise these measures. In addition to these quantitative measures, we included an open-ended question asking providers to share responses to the question: “Please tell us how this training impacted you.” Table 1. Post-IDEAS Measures of Acceptability and Feasibility To measure change in provider stigma we administered a pre/post Acceptance and Action Questionnaire – Stigma 16 . The AAQ-S has been shown to be a valid and reliable measure of enacted stigma, with good internal consistency (Cronbach's alpha = 0.84). 16 The pre-survey collected demographic information alongside the AAQ-S questions and was administered as a virtual survey just prior to the IDEAS training. The post-AAQ-S questions were combined with AIM and FIM questions and administered via a virtual survey immediately following the IDEAS training. Post-surveys also included an open-ended item asking providers to share how they were impacted by IDEAS. Surveys prompted participants to generate a code that allowed us to match pre/post surveys while maintaining participant anonymity. A sample size of 20 matched pre-post AAQ-S surveys achieved 90% power to detect a mean difference in AAQ-S scores between 7–10 points assuming a standard deviation of the differences in AAQ-S scores in the range of 7–9 points, alpha = 0.05, using a two-sided paired t-test. Previous studies yielded approximately 20–30% unmatched surveys, so the sample size was inflated to 26 matched surveys to account for dropout. Power analysis was performed using PASS 2019. TGD Veteran Data Collection TGD Veteran patients with mental health or primary care appointments were identified using ICD-10 codes for gender identity disorder as well as through patient chart reviews. TGD Veterans were sent a letter describing the study and providing the opportunity to opt out via a phone call to the study team and then received a follow-up call (unless they opted out) from the research assistant who shared information about study participation, answered questions, and conducted the informed consent process. Veterans who consented to participate engaged in a survey with the research assistant immediately following their pre-intervention mental health or primary care appointment. Pre-surveys were completed with TGD Veterans prior to their provider’s opportunity to attend IDEAS, and post-surveys were completed after their provider’s opportunity to attend IDEAS. However, we did not exclude Veterans whose providers did not attend IDEAS. All TGD Veterans with primary care or mental health appointments in the recruitment window were included, and inclusion criteria were confirmed during the initial conversation with the research assistant. The TGD Veteran patient survey consisted of items from the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Item Set (CAHPS-CC; quantitative). The CAHPS-CC is an open access assessment available through the Agency for Health Care Research and Quality (AHRQ) that explores several domains of “cultural competence” such as positive and negative provider communication behaviors, shared decision making, equitable treatment, and trust. Questions are answered using Likert-type rating scales. Patients were asked to complete only 1 pre and 1 post survey per provider. Surveys were administered face-to-face or by phone call, and the interviewer wrote memos to capture comments and/or explanations related to responses offered by Veterans as they completed surveys. We aimed to recruit 25% of TGD patients receiving primary care and/or mental health VA services within the study site location (one Midwestern US state) during the recruitment period, which was defined as patients with an appointment within 6 months prior to and following IDEAS implementation with providers. We deemed this percentage to be a feasible goal given the study duration and existing number of TGD patients in the healthcare system from which we were recruiting. 17 According to the local VA LGBTQ + coordinator, approximately 75 gender diverse Veterans were seeing primary care or mental health providers once or more within 6–9 months within our study setting and timeline. Thus, our feasibility benchmark was set at 18 Veterans (approximately 25% of 75). Our goal regarding feasibility was that 18 TGD Veterans would complete the informed consent process and both baseline and follow-up surveys, including the CAHPS-CC survey described above as well as a survey created by the authors, designed to detect more nuanced experiences specifically pertinent to the TGD population. This benchmark was created as a precedent for a future national study powered to detect meaningful pre/post changes in TGD Veteran experiences with their providers. Based on the number of TGD Veterans receiving VA care nationally, a 25% percent recruitment rate would adequately facilitate this goal. Analyses AAQ-S surveys provide a composite score, with lower scores indicating reduced enacted stigma. An unadjusted two sample paired t-test was used to assess the change in AAQ-S scores in matched pre-post surveys. Adjusted effects using Generalized Linear Mixed Models (GLMM) allowed for adjustment for relevant covariates and incorporation of random effects to account for possible sources of heterogeneity in AAQ-S scores. All analyses were performed in SAS 9.4 and all tests were performed using a significance level 0.05. We performed basic content analysis 18 of the qualitative feedback collected from providers via the open-ended survey question regarding their experience of IDEAS. This study was not powered to detect meaningful change in patient CAHPS-CC pre/post outcomes but rather, to explore the feasibility of this nested data collection method to inform a future, larger trial powered to assess the impact of IDEAS (and resulting provider stigma reduction) on TGD Veterans. We tracked how many total matched pre/post surveys we collected from TGD Veteran patients. In addition, trends in pre/post CAHPS-CC surveys are reported below alongside qualitative data from memos, which were drafted while patients completed surveys. In addition to using the CAHPS-CC, we collected TGD Veteran data using the Occupational Therapy Gender Affirming Care (OGA; blinded citation) survey, which is an author-created survey that asks questions about aspects of healthcare that TGD patients deemed to be important. This survey’s psychometric characteristics has yet to be studied. It was therefore solely used as an adjunct to the existing, validated CAHPS-CC items to collect information more closely tied to the TGD population and as a means of further exploration of the utility of this new instrument. Results Provider Participant Characteristics Provider participant demographic characteristics and comparison of baseline AAQ-S scores are listed in Table 2 . Thirty providers completed a pre-test only, and 45 providers completed both a pre and matched posttest. We found no significant demographic differences between providers who completed matched pre/posttests and those who only completed a pretest (Table 2 ). We found no significant differences between primary care versus mental health providers (data not shown). However, the group who completed both pre and posttests scored higher on the pretest (indicating higher stigmatizing thoughts) than those who only completed a pretest. Table 2 Provider participant characteristics Baseline Characteristic Matched No (N = 30) Yes (N = 45) Total (N = 75) P-value Age (years) , n (%) 0.3684 1 25–34 4 (13.3%) 11 (24.4%) 15 (20.0%) 35–44 9 (30.0%) 18 (40.0%) 27 (36.0%) 45–54 7 (23.3%) 9 (20.0%) 16 (21.3%) 55–64 9 (30.0%) 6 (13.3%) 15 (20.0%) 65–74 1 (3.3%) 1 (2.2%) 2 (2.7%) Hispanic/Latino/Spanish Origin , n (%) 0.2176 1 No 29 (96.7%) 45 (100.0%) 74 (98.7%) Yes 1 (3.3%) 0 (0.0%) 1 (1.3%) White , n (%) 0.4480 1 No 9 (30.0%) 10 (22.2%) 19 (25.3%) Yes 21 (70.0%) 35 (77.8%) 56 (74.7%) Black/African American , n (%) 0.3099 1 No 25 (83.3%) 41 (91.1%) 66 (88.0%) Yes 5 (16.7%) 4 (8.9%) 9 (12.0%) American Idian/Alaskan Native , n (%) 0.4111 1 No 30 (100.0%) 44 (97.8%) 74 (98.7%) Yes 0 (0.0%) 1 (2.2%) 1 (1.3%) Asian , n (%) 0.2239 1 No 29 (96.7%) 40 (88.9%) 69 (92.0%) Yes 1 (3.3%) 5 (11.1%) 6 (8.0%) Native Hawaiian or Pacific Islander , n (%) 0.2176 1 No 29 (96.7%) 45 (100.0%) 74 (98.7%) Yes 1 (3.3%) 0 (0.0%) 1 (1.3%) Are you a current or former military service member , n (%) 0.4191 1 Not a service Member 28 (96.6%) 40 (88.9%) 68 (91.9%) Current Member 0 (0.0%) 2 (4.4%) 2 (2.7%) Former Member 1 (3.4%) 3 (6.7%) 4 (5.4%) Missing 1 0 1 Select the option that best describes your role , n (%) 0.4927 1 Mental health provider 18 (60.0%) 32 (72.7%) 50 (67.6%) Primary Healthcare Provider 11 (36.7%) 10 (22.7%) 21 (28.4%) Veteran Panelist 0 (0.0%) 1 (2.3%) 1 (1.4%) Other 1 (3.3%) 1 (2.3%) 2 (2.7%) Missing 0 1 1 What is the highest degree or level of school you have completed , n (%) 0.6584 1 Associate Degree 0 (0.0%) 1 (2.2%) 1 (1.3%) Bachelors Degree 2 (6.7%) 1 (2.2%) 3 (4.0%) Masters Degree 15 (50.0%) 22 (48.9%) 37 (49.3%) Doctorate/Professional Degree 13 (43.3%) 21 (46.7%) 34 (45.3%) Gender , n (%) 0.1931 1 Cisgender female (my gender matches my sex at birth) 26 (86.7%) 31 (68.9%) 57 (76.0%) Cisgender male (my gender matches my sex at birth) 3 (10.0%) 12 (26.7%) 15 (20.0%) Transgender male 0 (0.0%) 1 (2.2%) 1 (1.3%) Non-binary 1 (3.3%) 0 (0.0%) 1 (1.3%) Other 0 (0.0%) 1 (2.2%) 1 (1.3%) 1 Chi-Square p-value Provider Stigma Table 3 illustrates change in provider stigma. Among the 45 providers with matched AAQ-S pre and post scores we found an average change score of -4.5 (11.61) among mental health providers and − 6.7 (13.85) among primary care providers, with a total average change score of -5.0 (12.04) indicating a decrease in provider stigma in both groups after engaging in IDEAS (p < 0.01). Change scores within this population ranged from − 54 to 10. The change scores among mental health versus primary care providers were not significantly different from one another (p = 0.87). Table 3. Pre/post Change in AAQ-S Feasibility, Acceptability, and Qualitative Feedback Regarding IDEAS acceptability, all items on the AIM were rated above 4 (agree), with a total acceptability average score of 4.33. Average scores were as follows, with the minimum and maximum values for each item being 3 (neither agree nor disagree) and 5 (strongly agree) respectively: IDEAS meets my approval (4.39); IDEAS is appealing to me (4.34); I like IDEAS (4.32); and I welcome IDEAS (4.24). IDEAS was also feasible according to provider ratings, with a total feasibility score of 4.26 and item scores as follows: IDEAS seems implementable as an ongoing training (4.24); IDEAS seems possible to implement in the future (4.29); IDEAS seems doable as an ongoing training (4.27); and IDEAS seems easy to use (4.22). Feasibility items also had a minimum and maximum value of 3 and 5, respectively. Of the 56 posttests completed, 24 providers offered qualitative feedback about IDEAS. All feedback was positive and spoke to the value of the film and guest speakers (e.g., “It really put a face to the issue and made me think about what I can do to ensure that I am treating trans Veterans with the care and respect they deserve”) as well as the impact IDEAS had on providers’ motivation and self-efficacy to initiate change. For instance, one provider noted: “The first vignette in the video posed a challenge to providers to help shift the culture of the VA…this is a lofty but important goal that I would love to participate in.” Another expressed that: “Some of it was really eye opening and makes me feel more sensitive to the good and bad experiences that might emerge. I feel more empowered that my interactions with transgender folks can make a big difference.” Impact of IDEAS on Gender Diverse Veterans Thirty-seven gender diverse Veterans completed surveys prior to IDEAS implementation, and 18 completed surveys following IDEAS implementation. All the Veterans who completed a posttest had a matched pretest, thus we were able to meet our benchmark for feasibility success regarding TGD Veteran participant recruitment. Post-survey completion was limited by project staffing changes which posed challenges to follow-up data collection. Table 2 describes TGD Veteran participant characteristics as well as average pre/post scores on both surveys (CAHPS-CC and Occupational Therapy Gender Affirming Care Survey), average change on each item, and total change on each survey. Table 4 TGD Veteran Characteristics and Survey Responses Demographic Characteristics Frequency Percentage Age 18–34 6 16 35–64 20 54 65+ 10 27 No answer 1 3 Ethnicity Hispanic, Latino, or Spanish origin? 0 0 Race* White 34 92 Black or African American 4 11 American Indian or Alaska Native 3 8 Military Status Current service member 2 5 Former service member 34 92 No answer 1 3 Education Less than high school diploma 1 3 High school degree or equivalent 6 16 Some college, no degree 8 22 Associate degree 8 22 Bachelor’s degree 8 22 Master’s degree 4 11 Doctorate or professional degree 1 3 No answer 1 3 Gender Transgender female 18 49 Transgender male 11 30 Non-binary 3 8 Other 4 11 No answer 1 3 * note. Numbers for race do not equal 37 or 100% due to identification with multiple races among participants CAHPS-CC Survey Pre (max/min) Post (max/min) Change Communication – Positive Behaviors (1 Never, 2 Sometimes, 3 Usually, 4 Always) In the last 12 months, how often did this doctor explain things in a way that was easy to understand? 3.65(4/2) 3.76(4/3) 0.11 In the last 12 months, how often did this doctor listen carefully to you? 3.68(4/2) 3.88(4/3) 0.20 In the last 12 months, how often did this doctor spend enough time with you? 3.49(4/2) 3.76(4/2) 0.27 In the last 12 months, how often did this doctor show respect for what you had to say? 3.92(4/3) 4.0(4/4) 0.08 In the last 12 months, how often did this doctor give you easy to understand instructions about taking care of these health problems or concerns? 3.68(4/2) 3.82(4/3) 0.14 Communication – Negative Behaviors (1 Always, 2 Usually, 3 Sometimes 4 Never) In the last 12 months, how often did this doctor interrupt you when you were talking? 3.81(4/2) 3.88(4/3) 0.07 In the last 12 months, how often did this doctor talk too fast when talking with you? 3.73(4/2) 3.82(4/3) 0.09 Communication – Negative Behaviors (1 Yes Definitely, 2 Yes Somewhat, 3 No) In the last 12 months, did this doctor ever use a condescending, sarcastic, or rude tone or manner with you? 2.97(3/2) 3.0(3/3) 0.03 Shared Decision Making (0 No, 1 Yes) In the last 12 months, did this doctor talk with you about the pros and cons of each choice for your treatment or health care? 0.76(1/0) 0.88(1/0) 0.12 In the last 12 months, when there was more than one choice for your treatment or health care, did this doctor ask which choice you thought was best for you? 0.73(1/0) 0.94(1/0) 0.21 Equitable Treatment (1 Always, 2 Usually, 3 Sometimes, 4 Never) In the last 12 months, how often have you been treated unfairly at this doctor's office because of your race or ethnicity? 3.95(4/3) 4(4/4) 0.05 In the last 12 months, how often have you been treated unfairly at this doctor's office because of the type of health insurance you have or because you don't have health insurance? 4.0(4/4) 4.0(4/4) 0.0 Trust (0 No, 1 Yes) Do you feel you can tell this doctor anything, even things that you might not tell anyone else? 0.78(1/0) 0.94(1/0) 0.16 Do you trust this doctor with your medical care? 0.95(1/0) 1.0(1/1) 0.05 Do you feel this doctor always tells you the truth about your health, even if there is bad news? 0.97(1/0) 1.0(1/1) 0.03 Do you feel this doctor cares as much as you do about your health? 0.84(1/0) 0.94(1/0) 0.10 Trust (1 Never, 2 Sometimes, 3 Usually, 4 Always) In the last 12 months, how often did you feel this doctor really cared about you as a person? 3.59(4/1) 4.0(4/4) 0.41 Occupational Therapy Gender Affirming Care Survey Higher scores indicated more desirable services. All items scored as follows unless otherwise indicated by * (1 Strongly disagree, 2 Somewhat disagree, 3 Neither disagree nor agree, 4 Agree, 5 Strongly Agree) My provider listens carefully to me. 4.68 5 0.32 When there is more than one choice for my treatment or health care, my provider asks which choice I think is best for me. 4.35 4.61 0.26 I feel my provider always tells me the truth about my health, even if there is bad news. 4.81 5 0.19 My provider explains things in a way that is easy to understand. 4.51 4.83 0.32 My provider shows respect for what I have to say. 4.70 4.94 0.24 I feel my provider spends enough time with me. 4.14 4.83 0.69 *I feel that I am treated unfairly at my provider's office because of my race, ethnicity, or gender identity. (Reverse scored: 1 Strongly agree, 2 Somewhat agree 3 Neither agree nor disagree, 4 Somewhat disagree, 5 Strongly disagree) 4.70 4.83 0.13 I trust my provider with my medical care. 4.75 5 0.25 My provider believes me when I share my health concerns. 4.59 4.83 0.24 My provider is knowledgeable about my gender identity and related healthcare treatment. 4.27 4.83 0.56 *I must advocate for myself in order for my provider to treat me with appropriate care related to my gender identity. (Reverse scored: 1 Strongly agree, 2 Somewhat agree 3 Neither agree nor disagree, 4 Somewhat disagree, 5 Strongly disagree) 3.46 4.39 0.93 My provider acknowledges all of my identities when providing holistic care. 4.43 4.61 0.18 My provider explains the purpose of medical procedures and professionals who are involved in my care. 4.68 4.50 0.18 All the staff at my provider's office affirm my gender. 3.92 4.22 0.30 My provider listens to my feedback and makes appropriate changes. 4.43 4.89 0.46 My provider fully addresses and resolves my medical concerns 4.39 4.50 0.11 *My provider asks me to educate them about my gender identity, and/or I need to educate my provider to ensure that I am provided proper care. (Reverse scored: 1 Strongly agree, 2 Somewhat agree 3 Neither agree nor disagree, 4 Somewhat disagree, 5 Strongly disagree) 3.27 4.12 0.85 (referring to prior question) Is this a positive thing or is it a frustrating thing? (0 Not applicable, 1 Frustrating, 2 Positive) 0.86 0.86 0 My provider acknowledges and understands my gender identity. 4.54 4.88 0.34 My provider acknowledges the potential dysphoria related to certain tests and procedures and takes steps to alleviate the potential for dysphoric harm. 3.83 4.35 0.52 My provider is sensitive to potential dysphoria and limits requests to ask me to take off my clothes. 3.78 4.24 0.46 Total Score/Average Score 87.09(4.15) 94.26(4.49) 7.17(0.34) Discussion We observed an average pre/post change score of -5 among healthcare providers, indicating the possibility that IDEAS may decrease enacted provider stigma. The AAQ-S measures psychological flexibility and inflexibility regarding stigmatizing thoughts, with decreasing enacted stigma being conceptualized as an increase in the former and a decrease in the latter; an improved score suggests a provider may still experience stigmatizing thoughts but has greater flexibility regarding whether and how they respond to such thoughts. 16 A change score of -5 is smaller than that observed in prior studies of non-VA providers, 10 suggesting the need for future exploration of IDEAS among providers in different settings and different clinical backgrounds that also examines qualitative experiences of providers surrounding IDEAS. Although this study was not powered to detect meaningful pre/post change on TGD Veteran surveys, it is worth noting the trend in pre/post scores on both surveys. All but one of the CAHPS-CC items improved from baseline to follow-up, suggesting a positive trend in which Veterans perceived providers to be demonstrating increased cultural competence after IDEAS training. No item scores decreased from baseline to follow-up, and one item remained the same: In the last 12 months, how often have you been treated unfairly at this doctor’s office because of the type of health insurance you have or because you don’t have health insurance? The average response to this item at baseline and follow-up was 4 (Never), which makes sense given that private health insurance status does not influence access to VA healthcare. On the Occupational Therapy Gender Affirming Care Survey only one item decreased from baseline to follow-up: My provider explains the purpose of medical procedures and professionals who are involved in my care . The average baseline score of 4.68 (agree/strongly agree) decreased by 0.18 points to 4.50, still falling in the agree/strongly agree range. The occupational therapist research assistant took memos while conducting pre and post surveys. Some observations from these memos illustrate factors that may have impacted scores and could provide directions for future evaluation. First, some Veterans had conditions that they reported contributed to them scoring their providers lower than average. For example, one autistic non-binary young person scored their provider notably lower than average on the pre-CAHPS-CC, reporting that they felt negatively about most healthcare experiences, due to providers not allowing time for cognitive processing. This is reflective of existing literature documenting that gender diverse patients with comorbid conditions face greater health disparities, resulting in lower overall patient satisfaction. 19 Second, it was consistently noted that Veterans over 55 described generally lower standards for gender affirming care. For example, a positive assessment of a provider may be one that does not blatantly deny the existence of gender diversity, even if the provider was not knowledgeable regarding the range of gender diverse identities and associated specific care considerations. Veterans over 55 were more likely to describe having a long relationship with their provider, whom they felt knew them as a person, which they reported contributed to positive perceptions of providers even when the providers were not knowledgeable about their gender and related healthcare needs. By contrast, younger TGD Veterans had higher expectations that providers were knowledgeable and affirming about their identities and care requirements. Third, several respondents noted that one of the survey questions regarding whether providers spend enough time with the patient is perceived as an issue with the VA system rather than the provider and therefore Veterans were resistant to scoring providers low on this item. Therefore, it is worth noting that there may be more systemic VA issues impacting care that are not captured by baseline or follow-up scores from this study. A study by Kcomt 20 discussed the importance of addressing institutional policies to decrease profound discrimination of transgender and gender diverse patients. Our findings reflect the importance of evaluating the larger institutional factors impacting healthcare quality, which would not be captured by surveys about satisfaction with healthcare providers. Many such measures are in place, further illuminating how patient care depends on a number of personal and contextual factors within a healthcare system that require evaluation and remediation. Some Veterans noted that front desk staff misgender them over the phone, even when they believe that pronouns are clearly visible within the Veteran’s medical record. Veterans also noted that care from residents was markedly less affirming than care from their typical attending providers, indicating the importance of gender affirming care training requirements for trainees as they step into their professional identities and responsibilities as primary care and mental health providers. Current educational curricula focused on TGD populations in medical school is “largely composed of one-time attitude and awareness-based interventions”, which has been deemed inadequate to target these systemic inequalities. 21 A shift towards a more clinical-skills based curricula that is woven throughout medical school may facilitate bridging the gap between systemic barriers and healthcare inequities experienced by the TGD population. 21 Limitations This study’s findings are limited to VA healthcare facilities within one Midwestern state, and primarily referred to experiences within a large VA hospital in a central, urban location. As such, Veteran survey responses do not adequately reflect TGD VA experiences across the United States. For example, one Veteran mentioned traveling across state lines to receive gender affirming care. This Veteran expressed that their survey responses were specific to the study location (which is where they traveled to for care) but would misrepresent the other VA system in which they had received less gender-affirming care. They specifically discussed their perception that the VA was not as a whole gender affirming, requiring them to seek out specific places within the VA that were equipped to provide them with good care. Given this perception of the VA system in which our study was set, findings (largely positive patient satisfaction pre and post IDEAS) should be interpreted in this context. The contrast in quality of TGD healthcare based on location has been echoed by Gonzales 22 which found TGD adults who seek care in states with stronger TGD protections report less mental distress versus their TGD peers who seek care in states with fewer TGD protections Conclusions IDEAS is a feasible, acceptable, and effective intervention for reducing provider biases that may negatively impact healthcare equity for TGD Veterans. Further research is needed to measure the impact of IDEAS provider trainings on the care of TGD Veteran patients. However, preliminary results are promising regarding the perceptions of providers following IDEAS trainings among TGD Veterans. Existing open-access surveys such as the CAHPS-CC items capture some information regarding healthcare experiences but may benefit from additional items that inquire about priorities identified by TGD patients. Further evaluation of such assessments is warranted. Abbreviations VA: Veterans Affairs TGD: Transgender and gender diverse AIM: Acceptability of Intervention Measure FIM: Feasibility of Intervention Measure AAQ-S: Acceptance and Action Questionnaire – Stigma CAHPS-CC: Consumer Assessment of Healthcare Providers and Systems – Cultural Competence ICD: International Classification of Diseases AHRQ: Agency for Healthcare Research and Quality Declarations Ethics approval and consent to participate : All participants completed the informed consent process in accordance with the Declaration of Helsinki. This study was approved by Indiana University IRB number 16200 and VA Research and Development as exempt. Consent for publication: n/a Funding: This study was funded by the US Department of Veterans Affairs Pilot Grant number I21HX003615-01A1 Author Contribution S.W. made substantial contributions to the conception of this work and wrote the main manuscript text including tables 1, 3, and 4.J.B. and M.U. made substantial contributions to the conception of this work, assisted in qualitative analysis, and helped with manuscript preparation. F.P. made substantial contributions to the design of this study, prepared table 2, and completed the quantitative analyses and analytic reports.D. B. made substantial contributions to the conception and design of this work and made substantial revisions to this manuscript. All authors reviewed and approved this manuscript. Acknowledgments: This study would not have been possible without the participation of providers and those who so willingly shared their stories Data Availability Data are provided within the manuscript - supplementary information is available by emailing the corresponding author. References Gates GJ, Herman JL. Transgender military service in the United States. The Williams Institute at UCLA School of Law; 2014. Available from: http://www.jstor.org/stable/resrep35579 Schvey NA, Klein DA, Pearlman AT, Kraff RI, Riggs DS. Stigma, health, and psychosocial functioning among transgender active duty service members in the US military. Stigma Health. 2020;5(2):188. Boyer TL, Youk AO, Haas AP, Brown GR, Shipherd JC, Kauth MR, et al. Suicide, homicide, and all-cause mortality among transgender and cisgender patients in the Veterans Health Administration. LGBT Health. 2021;8(3):173–80. 10.1089/lgbt.2020.0235 . Valentine SE, Shipherd JC, Smith AM, Kauth MR. Improving affirming care for sexual and gender minority veterans. Psychol Serv. 2021;18(2):205–15. 10.1037/ser0000378 . Brown GR, Jones KT. Mental health and medical health disparities in 5135 transgender veterans receiving healthcare in the Veterans Health Administration: a case–control study. LGBT Health. 2015;3(2):122–31. 10.1089/lgbt.2015.0058 . Correro AN, Hinrichs KL, Nathan S. My life, my story and identity disclosure among transgender and gender diverse veterans: A program evaluation. Transgender Health. 2021;7(6):556–60. 10.1089/trgh.2021.0004 . Blosnich JR, Marsiglio MC, Gao S, Gordon AJ, Shipherd JC, Kauth M, et al. Mental health of transgender veterans in US states with and without discrimination and hate crime legal protection. Am J Public Health. 2016;106(3):534–40. 10.2105/ajph.2015.302981 . Kauth MR, Blosnich JR, Marra J, Keig Z, Shipherd JC. Transgender health care in the US military and Veterans Health Administration facilities. Curr Sex Health Rep. 2017;9:121–7. Shipherd JC, Kauth MR, Firek AF, Garcia R, Mejia S, Laski S, et al. Interdisciplinary transgender veteran care: Development of a core curriculum for VHA providers. Transgend Health. 2016;1(1):54–62. 10.1089/trgh.2015.0004 . Wasmuth S, Belkiewitz J, Miech E, Li C, Harris A, Hernandez J, et al. A hybrid type III analysis of a filmed story-telling intervention’s impact of provider stigma. OTJR Occup Ther J Res. 2024;1–10. 10.1177/15394492241260022 . Kemp CG, Wagenaar BH, Haroz EE. Expanding hybrid studies for implementation research: Intervention, implementation strategy, and context. Front Public Health. 2019;7:325. 10.3389/fpubh.2019.00325 . Lee JL, Hirsh A, Radhakrishnan A, Jasuja GK, Taylor S, Dickinson S, et al. Mental health utilization among transgender veterans. JAMA Netw Open. 2025;8(1):e2454694. 10.1001/jamanetworkopen.2024.54694 . Copeland LA, Wolfe HL, Jackson SS, Buljubasic N, Kauth MR, Hashemi L. Treating transgender and gender-diverse veterans in the Veterans Health Administration: 23 years of findings. LGBT Health. 2025. 10.1089/lgbt.2024.0314 . Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health Ment Health Serv Res. 2010;38(2):65–76. 10.1007/s10488-010-0319-7 . Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. 10.1186/s13012-017-0635-3 . Levin ME, Luoma JB, Lillis J, Hayes SC, Vilardaga R. The Acceptance and Action Questionnaire – Stigma (AAQ-S): Developing a measure of psychological flexibility with stigmatizing thoughts. J Contextual Behav Sci. 2013;3(1):21–6. 10.1016/j.jcbs.2013.11.003 . Stewart AL, Nápoles AM, Piawah S, Santoyo-Olsson J, Teresi JA. Guidelines for evaluating the feasibility of recruitment in pilot studies of diverse populations: An overlooked but important component. Ethn Dis. 2020;30(Suppl):745–54. 10.18865/ed.30.s2.745 . Drisko J, Maschi T. Content analysis. 2015. 10.1093/acprof:oso/9780190215491.001.0001 Wolfe HL, Vimalananda VG, Wong DH, Reisman JI, Rao SR, Shipherd JC, et al. Patient characteristics associated with receiving gender-affirming hormone therapy in the Veterans Health Administration. Transgend Health. 2022;9(2):151–61. 10.1089/trgh.2022.0040 . Kcomt L. Profound health-care discrimination experienced by transgender people: Rapid systematic review. Soc Work Health Care. 2018;58(2):201–19. 10.1080/00981389.2018.1532941 . Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, Morrison SD. Transgender health care: Improving medical students' and residents' training and awareness. Adv Med Educ Pract. 2018;9:377–91. 10.2147/AMEP.S147183 . Gonzales G, Tran NM, Bennett MA. State policies and health disparities between transgender and cisgender adults: Considerations and challenges using population-based survey data. J Health Polit Policy Law. 2022;47(5):555–81. 10.1215/03616878-9978117 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 10 Mar, 2025 Editor assigned by journal 07 Mar, 2025 Submission checks completed at journal 07 Mar, 2025 First submitted to journal 04 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6156715","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":425468929,"identity":"085671c8-150c-4ed1-8e80-29bd3df9909c","order_by":0,"name":"Sally Wasmuth","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArUlEQVRIiWNgGAWjYBCDBH5mEMVGvA6DBMlmkrUYHCBWi/yM5Mefbrb9yTM+zmPA8KHsMBHG30gzk85tMyg2O8xjwDjjHDFapBPMmIFaErcBtTDzthGhRX52+ufPIC2bm4Fa/hKjheF2jgHIYYkbmIFaGInRYnD/TZl0zjnjxBmH2QoO9pxLJ8JhPcc3f84pk0vs7z+88cGPMmsiHIYMDpCofhSMglEwCkYBLgAAaDI5C2ot0k0AAAAASUVORK5CYII=","orcid":"","institution":"Indiana University","correspondingAuthor":true,"prefix":"","firstName":"Sally","middleName":"","lastName":"Wasmuth","suffix":""},{"id":425468930,"identity":"c0796493-f4f8-4103-94e2-f7ce0e5b0627","order_by":1,"name":"Johnna Belkiewitz","email":"","orcid":"","institution":"Indiana University","correspondingAuthor":false,"prefix":"","firstName":"Johnna","middleName":"","lastName":"Belkiewitz","suffix":""},{"id":425468931,"identity":"2bfdeb9b-488d-4ce2-893f-e1a77d911df7","order_by":2,"name":"Francis Pike","email":"","orcid":"","institution":"Indiana University","correspondingAuthor":false,"prefix":"","firstName":"Francis","middleName":"","lastName":"Pike","suffix":""},{"id":425468932,"identity":"77428e45-5ad2-40df-8f5c-777d8170bcb6","order_by":3,"name":"Mio Ueki","email":"","orcid":"","institution":"Indiana University","correspondingAuthor":false,"prefix":"","firstName":"Mio","middleName":"","lastName":"Ueki","suffix":""},{"id":425468934,"identity":"c5b0986e-c01f-419c-b70c-068f952953be","order_by":4,"name":"Dawn Bravata","email":"","orcid":"","institution":"Richard L. Roudebush VA Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Dawn","middleName":"","lastName":"Bravata","suffix":""}],"badges":[],"createdAt":"2025-03-04 19:08:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6156715/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6156715/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24494-2","type":"published","date":"2025-10-01T15:57:48+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":92883800,"identity":"f673f997-2174-4b88-8ee1-95a867a06210","added_by":"auto","created_at":"2025-10-06 16:09:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1305793,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6156715/v1/bf3d7598-270d-447f-bd63-3c1620149446.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A pre/post quasi-experimental study of provider stigma and Veteran experiences surrounding a narrative “IDEAS” intervention to promote positive clinical encounters","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe US Department of Veterans Affairs (VA) has considered transgender adults to be a high priority population and has placed value on research that supports exemplary care for transgender and gender diverse (TGD) Veterans. Nearly 20% of the adult transgender population has served in the United States Military.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Regardless of political context, development and implementation of evidence-based, stigma-reduction interventions are urgent and critical to support the health and safety of TGD Veterans.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Forty percent of TGD Veterans attempt suicide and many report disaffirming healthcare experiences deterring them from seeking needed medical services.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e TGD Veterans are significantly more likely to have greater psychiatric and medical comorbidities compared to non-TGD Veterans.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Stigma exacerbates health disparities, as it can dissuade TGD Veterans from revealing their identities to healthcare providers who may not ask about gender identity, limiting delivery of affirming, comprehensive care.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e By contrast, affirming policies can decrease harm \u0026ndash; for instance, employment non-discrimination protections for TGD Veterans has been associated with a 26% decreased likelihood of mood disorders and 43% decreased likelihood of self-harm.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e VA research has examined health services utilization and barriers and facilitators to care from the perspectives of TGD Veterans and VA healthcare providers, but implementation of Veteran-informed, evidence-based interventions to improve affirming TGD patient care is needed particularly for providers who may not otherwise seek out this type of training.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIDEAS is an evidence-supported film-based intervention developed by occupational therapists to reduce provider stigma.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e IDEAS involves conducting narrative interviews with populations who have been harmed by provider stigma and creating a short film depicting experiences of healthcare inequity. The current study examined the impact and implementation of an IDEAS film that was created based on interviews with TGD Veterans about their healthcare experiences. We played the film for two VA provider populations \u0026ndash; primary care and mental health. The film screenings took place during regularly scheduled virtual team meetings and were followed by a reflective conversation between providers and TGD Veterans we invited to join the meeting.\u003c/p\u003e\n\u003ch3\u003ePurpose\u003c/h3\u003e\n\u003cp\u003e The purpose of this study was to measure the feasibility and acceptability of IDEAS implementation in VA mental health and primary care, and to assess change in pre/post provider stigma. A secondary aim of this project was to explore the methodological feasibility of examining IDEAS’ impact on TGD Veterans. We accomplished this by conducting satisfaction surveys with TGD Veterans that assessed the cultural competence and cultural humility of their providers prior to and following their providers’ engagement with the IDEAS training.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003ch2\u003eDesign\u003c/h2\u003e\n\u003cp\u003eWe used a hybrid type 2 design\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e to examine IDEAS implementation acceptability, feasibility, and effectiveness (decreased provider stigma). We also tested the feasibility of a nested data collection methodology for assessing whether IDEAS implementation with providers impacted care from TGD patients\u0026rsquo; perspectives.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThis study was reviewed by the Indiana University institutional review board and given exempt status \u0026ndash; study number 16200. Participants included 1) primary care providers and mental health providers from a Midwestern VA Medical Center who attended the IDEAS training; and 2) TGD Veterans within the Midwestern state where IDEAS was offered who had a primary care or mental health appointment within six months prior to and following IDEAS implementation with providers. All participants underwent the informed consent process.\u003c/p\u003e\n\u003ch3\u003eMeasures and Data Collection\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003eProvider Data Collection\u003c/h2\u003e\n \u003cp\u003eWe collected data from primary care and mental health providers because these two services were highly utilized by the TGD Veteran population.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Acceptability is defined as \u0026ldquo;the perception among implementation stakeholders that a given treatment, service, practice, or innovation is agreeable, palatable, or satisfactory,\u0026rdquo; and feasibility is \u0026ldquo;the extent to which a new treatment, or an innovation, can be successfully used or carried out within a given agency or setting\u0026rdquo;. \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e To measure acceptability and feasibility of IDEAS, we administered the Acceptability of Intervention Measure (AIM) and the Feasibility of Intervention Measure\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e to providers immediately after the IDEAS training. The AIM and the FIM demonstrate good substantive and discriminant content validity, structural validity, scale reliability, test-retest reliability, and sensitivity to change.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Questions are rated on a 5-point Likert scale from strongly disagree to strongly agree. We defined implementation success as an average score of at least 4 out of 5 (\u0026lsquo;agree\u0026rsquo;) on both measures. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the questions that comprise these measures. In addition to these quantitative measures, we included an open-ended question asking providers to share responses to the question: \u0026ldquo;Please tell us how this training impacted you.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003eTable 1.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePost-IDEAS Measures of Acceptability and Feasibility\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cimg 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6TNblvTMAWDr2pDtstpa2xiuDZlVJsqjLUpbRa6nxqgmHd95551tyHq9DoH61C0DKgOQHr/FthTz5Z7eZpBOzwygXSEDRP1yftxKjH6JK2hDqn/aBagvUS/a7hjzRa5mIEm6j/1umm2lpXaGrHpYJOkqju7BQ87aFq9mgE7tm3IjH5BebNtD4HzpDrQtm7KRVrQDNdCpdK740i3yS0+8ggniszbQKSA7dQXE1zlsV6VOiDdke9xQyAtbSFtqJkbp1XXkQb7qa7KV1It+K9mgiPSvOqlBPMqM7qnH2D5qtnRaSLOZRLbf1p8/IL3SlxhLhqJ6gnkeAroo0N8dd9wxueaaa6q3DsRxjTETSu1SrzKstUttvyW+zuHhRsSdtV0+8sgjqX444rMjeBWSiG1iq6CdRvnjuExZ+T3avBLoUnpTXM5TH1B/2kqirjTniHZN9TYEtRvqVmmoXLV5C/YEu53bE+SK+pUNBHRGusoDGZW+xgDOZ65FO6yNi4xNpKO2DbKlQ6i1s1K9UibqFXlqt/3xO2MzcWnn4oMPPmg/DSfOjagTzfeG3sKDTtX+9PA8ykt56NfSKTaEuJSLcoPaL/D6MaHPzLk0HlAHH3/8cfoMNZ0OhXbSONTpIG3ZauYLyKk5Neiho5pL1NDcBmLZaqCTe++9d3Lrrbdu2NF5Id84p4hjEmWO41UfapMQy2Z2B6N11uk4NHIZgTjAY1CjAyhimM7DoJ8+fToZUxl3DSDRwDDAMOicPXt2wzHXpAiDhtHkkAFGhvyeIsBgi+iYDe1cyEi5mWxxkPcsk8XYsRdleKYh1lcc8Jko9jlEyCuZo5GN9RUnAdvBPIMRbUX1H9uS2k+tfpjUkC864P26sW116TdOYmJbV74xv1LexJ2nvDXIWwNVrV7jJCFy7bXXtp/mJ056qBfsBoNo1GkX0illkE5j/5ZOyYc+jHNK3VHfmgwCbQFIRzrgXJ4FwASKBYpY5/OidsFESH2Q/FQnyKfyiPzhWBHk17l94CxL75Q32gAmgNLFvMS6JU3qlfJQD7O26TFMjLAFFy9eTJPZ6JRFeG8wzNsuRd4uWSxYRLtc9thE+6dsQP6SATswZCE5PhgxlkW6QueLas9D0HxlVtRuSEftRu2B/l3r43I0oj2BuBhHWlG/0cYSrrTJT3lLd7W2MW95a8R6VfuAWK8lW8DvihMpzQ/7QJcxLZxrdIR+6LN9RP2V7Ll0ylhA/ZFmHAtK6AIV6bKYzPOWkJH58qLQQjG2DfuSz8HJT2XRIkFfP5t2sQSdYF/xFxbZxuLiFfJqTMI/KLWbIYxhAdlsL6N11lk1ixMvDEtuxHJi54yTD85lABH6jY6jwYLOiaGUQSS8ZPRY1WMlm6PLUOREebpADlapuaLKanHfQ7yGMO/5s4C+NeBRDgYCjtpEMxIHxDhoRkqD5liJssZJCQMU7Sju/ojEiWAO+tWAIv0ysPFakdhPYt7Kl/asNrxIZ7CP2Adq9VqbMCwS7EHMn0kahyaffUin9CsmuuiUMOlUaWNL6MdcKWCxhVX7ms0gjiAOV3FqT9qfBWQqTQxi+2ChJ2+bXa80HGrT0JMWX0W07bRHXd2ZF9pzzIeFLK5KDXHCaizDftZggsdkslSXqo+tbpecsyiWoVt0F/u6dtewCBfbTo3YZ2p2LMYZO7K5cWyKY0SJmj0BxqU436rpN+oI50N549CTb21c3CrGUK/olHmowG4y141X7LuINpmFb+k0n2uQD3YEO8A5zDO1aJODPNF5RaZFzEsj8cJWROVB7yrL1VdfvdE2u+bgURfTgG2Idm9emPPGea/GpDgGTsusZTM7l1E663RIBgtW8XiqKwdP94zOC3G6JvZdV4QitTSiEeAzE5T8qBn0ecEIMoFiso5BXdQ7wLeTfEIkh2jo1UtRM8a1icLYoc3k7SgOzpH8HdMRyh8nRCxuod88LemP/8TP864NkltB3qeWRa47rvhgW2bpz0yicp3GgZmFFK5IMlFl1b62AEO95Sv6bDtc1O0eQ8qGbHlZuhYwhuqLKwmUS7acg62a8Xza7qKIjjm2lInNkEXCGmOzNdRTqR3FPrXIdsmutNgusTXU6SKI6W4n8WqXbhVCB9PW9TLt2KJQGZhzHT169Ip2U+rnfX0/jvPol8W4riuJXL3N862Ni9tBrV63wxZE3SEHY0Acr7qIcpfsedQp9c3tLRzkGftEhLrGRsS5AjaV8xZFzf6oPPzPy8LRZT+Gjk8lhizaTUNc9GJMojzzyLcsu2mWxyiddVYSmSCw6pcf0VjmV9ejc6PtMyXi1cTaamKMg2GadxWxZoxyyIdVSyZTrLzNOsmMRnsrHLIhxiKuHDJgo8chV3Kjrmp6384rwvMSZZ3mynHfxCDqF4ezNADEvGlTy2RIvQ7tJ/OC7qJ+p1nljjJ2XWlhQZFFN8qaOzw5pINjzD2gMX1tuZ+XWluatW0C5emzA7RJ7ktmspfb8riNkry7bPY0MNGKOpymbktsV5uchtJOgViXXe0SWzFNu8RRyNulrpbOyzyLKPOAndSEnDaK4zF090XUw24dn/rGJupVuxTRLzsy8n4Y863d/rSdjKVekSM6i/S/IfMtGFqX1Ak2AFtA+l0LI9gAZMKGs0VdMJ9Y1BXevvGJ+qjVSY156gp9L9JhZ4t9nJvNOyZtRzs042J0zjoGhkOGPkIHild6WN2PHTjeq0saehgGsIqo73qYCbDiGyc2nMckG2JnzR9mwVVvDF4X0ZDFB5OVOprSIh+VSfFmeVCJykQaJV3OS2lVMNcHeUuH6H/otjYG+tIkLtb1PNtaF8Vnn33WfqqDThjopC/qJV6V4vch778tEfULpQEg6pztV7GOcI7U1oeQ12+Jrji0w1K7if1vu+oVOWQvaGvTLGjFnS5cIY5lxsZIp3EbO3VFvNqEQw8FIh6TIukpTtJKE7Z5J0vxahftITrM9Nm+K6jIC7V6x75Gexuh7ep8GOIAItMQdHUKPc4y6YrliTIui7zcJfsY+/o07RJiu4x5adzrapfTEp2Iodt7F0HeRuMVTMpT0mmJfOeG0Gfa2zz6yRna5iO1/hhRnDg/yG+9YWyaJX+I4xE6yW1/bnviYjK65MrpIunTSW3sUb0ib3ToxRBdT0uUJbbTPhjTpFP6e7Tf1KPmGlyt17ire9JjW46QhuKyPZzdF6Kvnc/adkRX22QBqEv3N9xwQ/tptjoaag+GQJ2oP5DuLHPyWAbVmdk9jM5ZZ3LQNTmKgzuNNzrRGNO4Qsg2erbPY/RZOdeEnNVBdUTSYIVR9+JxjuLRuWT4mHSSFpMe0uIqvn6LYFBk2LS1k3hRLsqnczVB1mQ9GjfSyp9MyX2lcRFCMGlXPIwuMmBIeWBelDN2+JohrTkA8dYC9Kd0KScDQ76gARp0kKVrS23O8ePH03/KJJmVf17PkVi+LvJ4n376aftpnfz3Urr54BYHclasGRDRJXqKAy5tjLqlHml7cZFpqPxC+q0NAOhc/QldsgWZtkx7p950Tsy3JkO+aBTLS1lqEzu1J/Sg7WBMzJSP6hU91ByrWRashPpDjrb9lSZDsRy5Pmh70illow6lU3bqSKex37Fbhr4c5dA9hUDdaDJCX1GbiPZOT/cFrlZjN3jYT2RIPUaYQMerJdg2bBHlIe2+SYXaX0m/6J0Foi57Hm0CfSYuFkC+IJa3L8pIWN4XuVqE/vU/EvVSs4HR5i7rNqQhckaGtsuYFu2SI9p8dqyp/PRTjU20S42bNSc76i0Sxw49jZ5Jf832RXkitfTz8NhuscPYpryNkLds2DQOUdSz2j35I3+0cSViGbuYpu5LaVLWGB5tNfqnn2kegR2U00V9a4xgvsO4qN+Gyi7Qrxz0kn75LY7j5IsNJG8+03dLSI4oTy5bdGZo+yXbAtFuxXrVwgG/kzb1WnugWtR1LscQaDu5/WQcpM6Y66jPiTyP2D5ye85cg3ktfSCfawjmbeg7PqiW8qMzQVtQ/9HiK2mpbcT5IOeia+oy6rxLN3nfFHEOzqIB45PGJi6A5bY9EucSNbsxC7ltyvsnZaE+83CNRaVFoaibWn+PbaRUj2bFaV/htnQuXLiw6X2kjeHc9D5OaAbBTe+x1NFM+Da9G7bpFJt+bwzJFWkRn/AYr+ncV7y3mfcZNh1sIw6f8/fuRrkbg74p3cZ4Ft+JeOrUqfQ+RdIjX71DEjl1Pumeb9/ZTjqENQZ8472a/Jc8HPyGjki3lC96klxKn/zQdSyj9HXixIn0bk6Fk2Z8hyxlJS/i5HUQIQ55TAt5IRdyNgNQ+kz9x3zOte8flYwcpbYToVx5OyJtziNP0q+lqXrgoNzUo6CeqAN+43/UFeTtMj9f5dXv1EP8vQb6pUw1aCfEiXlTPt61qt9jG+agPdF+Yv2TRiwT+mgmE+k3ZKWtQq09idOnT2/UK+9uVb1KHiBOrmvkIb7CODhP/SGHelR/IC755fokLOaLHvN+wkHdxXNLOuW8mBb9gzKof/BuYNqrdBrrgLQ40BV5qT3mxHqijaFXfefgXMpNeIxLeuiuRt42kSXWWQ3yUl3LhkGsP/5TD7Ge+EyY+osOdEMdoCf1+fg7+uE88o39OIYL9Bdlou0SFtPjQE+cGyFtpbvd0M5KbZD20tXPYUi7pG+X2qV0TZjoa5d5u8EeqN3wGwdtgTQ4T3aVuo3k/Z3PagfkrXAO5CePPDzKFfWATKRTgjwoU2w3QyB98kdO+hWf0WfsM6Qp+yYZiddl04e0Uc6XDeGgDyFPPqah+wg6J5xzo64AuWOaHLGO+H0aeyLUx7vI2xA6jXMX6jvqkPqkvBp7dORtSn2I9KQ79Bv7B+mSvsBexHpFdvSisQ2o16gLDvKijcW0SSOOlznUo+pM+VEuQdukXwjSJ05eT8hL+eK5JZ3GPqD2y2/oUfnIHhMfuwDISbnIl3T5rDYXIQ3lh16RP8pBfpJBbVEHeoh9J0JbiPWf11kXsjd5W0W2vL+QLvLW6gzZkTvKwqG+Sbvgf9Sr2p3g/GiLa/29ZOsps34zu4+r+NM0gJVDq1tNx9q4Ul6COMRtjNOm1eccXQEjDnEjrErq96ZDp1V9VvJYIWs67sbq46JhNQ7ZG+OZvrPip1U/ykzZxwBXdlhZRxezwEotZS3pfqdBm9Aq76LaBm2YNtBX32qT5DlrXSySVajXRemUfksdqg93tQ30Rl0vug5lM2Ea+8EVFK7ccOWpmXi0oTsbrtxwVaiZTFV3e4yZZbTLHI2rQmMk6WnMWja0d64oNg5JGzIdmj+MxabOi2xy33xoKLRB9NOX1qy2Z6tQe9/J9RrnGvPoVP1Y6XXpRHrbijqcxX5gw7HlyMNtPDsZjUnyMczuYmWd9e2k5KzvZjDWGHVNctlCdfr06fTZGLNaMLlnIsFk7sKFC23ozoXJKbcssD2YLaRmdaCtMuFl8o4DwvZ4xmu+G2NWD2w4W/0Zm3bqwgvzaW5XOnbsmMekXcpo37O+U2EysJuh/LwSiHuLWMDg2ImvnjPGDIMrKFyBxlnnfsKdDjsFDh486EnRCsIuL8YmJu+MVdxLb0fdmNUFO37o0KFk13fi/JxxFdkpg8ek3Yud9QWjrVxm/enObDFcla2xxpgybI1kmyHODxOLnQiTInYB8SC/WbdFm50BV9dx2qd5sJwxZmeCPeehmDxwj51TOwV2qWKnkN1j0u7G2+DnhJUuPd0WmLTyCh1WwXYrPEWUp1WzzZBtO+jEGLM7YMFyEfe7bjdM4tglYHu1ulDHPO2eNoqjvt9PVTZm18CCLMdYnpnRh56b4DHJ2Fk3xhhjjDHGGGNGhrfBG2OMMcYYY4wxI8POujHGGGOMMcYYMzLsrBtjjDHGGGOMMSPDzroxxhhjjDHGGDMy7KwbY4wxxhhjjDEjw866McYYY4wxxhgzMrb81W2PP/745Nvf/nb7zRhjjNld7N27d/L9739/478xxhhjVoOtfgu6r6wbY4wxxhhjjDEjY8uvrBtjjDHGGGOMMWY6fGXdGGOMMcYYY4wZGXbWjTHGGGOMMcaYkWFn3RhjjDHGGGOMGRl21o0xxhhjjDHGmJGxMg+Ye+mllya33HLL5MCBA23I9Hzve99LRw7p3n///dVX0PE7BxCvxI9//OPBr7C77rrrJkeOHGm/1Xn22Wcnx44dm+zZs6cN6eaVV16ZvPvuu0mW++67b3Lw4MHJ7bffnnQ3JD9jls13v/vdycsvvzz54Q9/OFlbW2tDjTHA+PUv//IvyZ4PHRdyusYq0mW8KEF+99xzT/rMK+oYx0o899xz7ad+Dh06tDG21kBW8uMYAjbk7bff3niVHmMh8wbSIT+zmXvvvTfZ24sXL05uvPHGNnR7+eijj5LdZw5z5syZ6jxrN0E/ffXVV5NOLly40NtPaPevvfZasg8eO3c+b7755uThhx+enDx5cnL48OE21KwqK3NlnUkExov3uv/85z9vQ6eDAYDB+p133pk8//zzkxdffDEN4pow0CE+/vjjjd/ee++9dB758v3RRx+dXHPNNek/g0tE53/66afpfAaeEjjTpNUHE40XXnghGeA+0AcDLunefPPNGw4+Hf2mm27aKIcxY4Y2zzGkzRuzG2EMw2HGtjMuzQJjFeOpxioOHG+cbP3HadNvOL7AOIPz8OSTT06uv/76yQMPPJAcg5yjR4+mPHQ++eRonO0rA3myaI0TMoSnn346jc+c98wzz0xuu+22NBYjL/mZccIiFM7JT3/60zZkd4Me6FssMA3RCeMmc9LXX3+9DTHG7Ci4sr5KNA7x5Wai0X6bjVOnTrHb4HIz6WlDPufcuXPpt2ay0YZ8zieffHK5cezT782kJsXN6TpflPLNoYyks3///jakTjM5SnEvXrzYhqyDvHv37k0y71QuXbp0+eTJk+03sxvo6z/G7HZOnz6dxhHs46ysra2lvsZRSmfPnj3pN+LlHD9+fON3PpdQ2qXz4dixY8UxNHLmzJmUBuNtX1nPnj2b4vI/wnmMgbYp40Zznr42sdNgHkZ/nQXNN2t9KIc27nZuzM5j5e5Z56ox24IWcfVt2m2EXHVoHP105YDVzlmvbjz22GPtpzJcFWBFlfwoZ18erKay3Z0jInl3MmzJzHcxGGPMboZbnHTVeRGUxsKuLdGMgWxXBmSY5Yre/v370xjVBVfFG+cjjbd9ebz11lvpP/EjlI2tpMva4m2Gce2117afVgvmq/RVY4ypsXLOOgMug/yiJimzwIIBcjCBmGVrXd/9Jxh3bdkHth52gRzcc8ZWqJyuewvHDlvjvHXRGGOuhEVfxoplLWYyDrNoAGw/n9YhYTt/133ojGeMa8ePH0/f+8ZB6aG0ZR6Hfd++fe03Y7YHtvYvc65qjNkZjM5ZZ0DVfWUPPvhg+j/tqvxDDz2UBnIM4TJg4H/iiSfSZ2Qfck+RqD28J8Kk5Kmnntq4As9V9q6JkB7Gwn3rxM0hrT6oF+5VJA3gfinq59Zbb033zguu9LOj4I477qiWhXOJw7mkx2BVkh/dcd8j99XzP8quh2twHpMvfqfdCCap/H7XXXelNjRklwMTP+63JC6QH/JRlpi35EL+GI4eCNfB8xMifNdvXRNoyoTukEP9gLRjO1J9oBtAH8RDVsIjxOV85AXiIoPiRt3zmTLxm+4T5HPULXGkX9Ik36gHoE5VVo7YRiQr4bGNkIbqCr2T5zR9x5hVIdoA+gr9Ie+rffC8FeIPeQbKVsHCNWCDSg9vrTF0HGScZUGAxXHGldKCtOBBcoAtwhbntmXoQ5oYR6KdwtZF+yi6xi9B/VCvikdd5/f5kw75cD4yM0ZhdymDyot+CcdWE56PdfyueRUHn0mzD40zeVxkJB2NcdQXeVMO7WrUOMEYTLny3Y58Jw3Sp1zIpPEk10Ef6IjzpOs43gB6QlbJiy6Ri3JxrpC8pME4VYI4qi/+5/UqWdRf+a95SGyfpEMY0EdJK7Yj+gttDJmRk/qlPmooPvVA3GnGTuREZyrXNHVAmSgHB3Lyn7lUROkrDvJxDIF6iOmjj1wPeR9Bj+oLuSxdUGb1I9IjnTwv+hbh1CkgH3rne6mPg9o6toL/6IL64sj1zHfS4zkaNRlA7Szmqf5KHYLaPeUhT+ohB/0Qh/PIl/wkG4cZCe12+FHAvWO333775WbwbUPW70FHzGnuU7pw4UI6J6YzDbpnvXFy25DPGXLPOeheulz2rvP5jfJ2QbrcZy64L5H0CK/BverXXXfdhjycg46G8uGHH27cL4bc6If74PmPjgjnvkTunyJeDD9x4kSbyjr81kwi031a+i6ZIqTFPYtC92aRr5AuYzwgzZje+fPnU/m77utCH8oD2SmPyoi+CeczcRROWyU86p7yEsaRgx737NnTe38ZOmwmnxv3YKqcKjv1STshLcL5nfIit+pZbT+Wi4P7NSlPjMtnID/kJ2/CeRYAz0TgO3kpDnmRpqD8/E6ekhnUZqjvHNKObV33uKpdUmecG/MRhPf1P2N2MrR7+p3gnlbafW7r+qCPx3SmATtFnhwl6IP81mXPsAdKI5dd4fn5jA19z2LBllI2/gNpkxY2pwayyJZzoJeucbMEaWD3dd87smLHcjuFzYv36ssGRx1IHt2vrGfIEA+bDthJjTOkh40ljLGAMHSArURfMZx0IsgTx2LiEq+LfNwXlJ38CEceyk+5GBPVJpCfOArXmCL7TlmUBnFIh3GIsYUwxgLpQKiO83BkjGOJ4qlOpB/CyIf45I8ONAaSpuoshufzJGQkfZHXK2VVGagLfic/6THvi+RLOOdF1N+VP30EneT1qvyRWXMA1QFx43gM/BbrEojDueoL+h7H4xrolnjkD7Rhyoj+NMcD9IMOBOXL5SiBXiiL6lx60JwFyFt9hDZOPUr30sMQkCnaFP6jB8ojPRBGWyNd5Ec+tSm1mbwu+Y7MemaUdERcykHbFMjAb7KJxM1lANIkPOaHbOr/HPRTZEP35ENYPh/XPIv/IJtEGOlHPZvlMipnXYYrDnI1Y9YFjZZz6CC5sRoCeXF+qaFKnj5DQ8ciXi67zpfB0UF6hGuAqYEhkmEEPnNe7PAlMBTqhDowMNGg9oGMGCQZToi6LoVjLARhuREHyk9cTVrQXUm/kpt0QLqMgydgZOLgDbSprkmlID3yjoZRBi0PxxgSHgch0MQgf6Af7aCvfgFd5vWp9hKR3mL+yEdcwuNEVO1rSFzqLMalvqQ7dM05eb/SABYHA+IQl4Emj0/5VI9A28zrnO+cn0M+eVxjVgnsZG4DaPe5DehDk9hom4dCn+dcjhKyKX12VfFy26e0NSnk0BjV17+xM/nYwnnorWvMx5bJvulAz7mtriGbH20X+UW7ii2lTBHy5TzsmcY/bGk+TnEu8eL5xCMMuWPZmAsQnqehcSGOs+Sbz6FoG0OgLvL60NhLGlEXmjvl4Yy/hEcZpEvSjuOqxhLSiOWVHmJb5rxSOSgvcVWv/FeaUS7aEeG0u1J4lJe6IV6Ec4gX61U6oA5jHch5jGWVHvO6oU3mY5/qNaI0cdIEeaofxXAo1SVxaEsRtcM+e0O7J160AZJJDiAgT+4oxj5TA7lqeoj1pbZB/NhmSnFL8Dv5xLk1UFecn9c7cxpsTZw3qS5zO4e+c/3KqaYPCGQgzVxPNRk098/bDvnl4bLleX3yPW8PWijK5TDLZVTb4Bvjlu4/axp7G7K+5WRamo6U/rPlo2vb0HbRdMD20+cgY9O5N45mMNm4964GumBbStQPnxsjk7bZdG33aQapSWM8Ux7EB21di1uz+qAsTQdvv62XQ0cpPOpf283Ily03OlTHkp8tYeQT43CIvm1NjfFJW8ziOeipVA8lOL8xjO239fv6IQ9Hp5BvN2sGjvQ/v4eS7fpDbjlojOxGGoAOu2RvjGr7aV3WZrKTPuuBSpFa3DfeeCP9B7UPbicB8qbsQJk4T3GEbsmIryQkDukjf9wCSf3xG+1D0C6jbOiU/lvatmXMqtNMxDbZgFnGQVAf67OZW4n6cM2GNZPDjXGwmZhOmgnsFfYlBzsTbSnlbCbEyW7UtqICMpBfM8ne0A22qWsLa0R2kO3C0imy6rY3wM5T5jh2aVs/4TqPMmjbqg7Z7DgmK0/uqY960bb+Rx55JP0Xih/rnLKyvTXa4Whvu1B6JZizRTuuuHm4Psd2rLIwdsRxlXbPb8jf127RNXGjDjmUdqwjyOVSvvwvhUeorzwv5hlAveZ9lPqKbZ7X5sKQ7enoABsgOKfrvNj+yFPnDmnTbI/Oy8Xri6Fvbki+tKPYRjTni2M3umULeLzlYMhciNcrMh8SpCk9xPQFcxbVNUiuPvvJVnbSi3NYoB0Qhh7ilnDyQM/YHFHqJ+iCvKNMwCsjIeqX9kXZ8rbXJUMX0U+o6YEt93k6mtf6lc7jYlTOOo3m6NGjqRNgBLkfQ0ZjWtQ4ZTi2mzjIqPF3obLffffdbciV0JkxehhXGVU+q6x9D9hRHmtraxtOGvrhPpV59FQzGnn4Bx98kOo2DgocyHP58uX0GdAdBiqPRxyO3KDmYODJm4fPsRjBgIXe4sA5DbXy1WBCgPy0YemVMpUMcYmDBw+mNHSv1rQP0dPkrW+AAjnkfZMiIA7lKelD5SLPOKnQJIK2K/TMhcj+/fvTwMeAxP1TTCyN2a3kNiD2n2lY9jjIBFh5a4LaB7agayKPTkgTxzOOD5q8942DgK1h3MHRYFzgXOxOdCZKMJZTN9hCHHzOwebFMZ7vXeMX9YqN5MD+xjg4JsS5dOlSm1qdvvEsOjPok/yYU7HQwCQdPY8RxmrJ1jeGUQ+08ahDjk8++STpMTpT84Is1F2el+p1yNg+FPLB2YrjYazPPjgf6CdxPM6RfpkzxDLRLygTeuyCdn/kyJGUDzJiq0r5MQ9Afn6n/dF3ZZu6oBz0N+RED9xPPo0eRN85b7/9dvpfmtuobw+ZI+Vo3llrx1EHcSEtZx4ZukC/yFbSD7Kb8TC6B8yxcsRDRmg8rLD3vcasj2kdrUWhTkX+cSDvoza4oA+cTq5A4qzGQ1dgmGiUOl3+kAg6ISuvuoJBZ+2bpCwCDHrNaEWGxqvBoMlVGnRDPWDkWZDoGrQWDXVCXejhTiUHtYYmVVw1oJ44pmnHam9DztFgMSSu9FfSI+dr8hh/RxYmXrRBJh7ohP/UTYRzqCf0RRtn0jpNmY1ZJbCB2AB2vND/h14FrbGsvhTt+DTOTJeThS3FQYhjIAeLtIxt2BeOnHwcRCekw9V82cG4w6iGdj5xPmMyTjsLCGLI+EUcmGecmwbKyW4C6gA98OCq2oNdx8DQMQz9bZcO552XTAP1wnjIQVujzU3rPA0Z29UO53ECuWDE/Iq5OrtWSvNd+rPmZLQ/bBtlG9L+WDyYRw9D0EPepI/IDTfc0H6aDRYbSF95AFet0VO0c6W8hWQozb3mgUUa6kA7RID6YS4Xd2uY5TMqZ53GTCfGqWFwiUw7qKhRlwzHVkPeWt2fdpIlQ4TxjGWmM2Ho6NxxgsKBMeA/nT1OGkTtqgxOlPS8aCNQQoNHSUbQgMGEgrZQMl7oZMhEiBVDBgcWJNApeQ55wvCioJ4oL/WGvBhA6qkPZGfyRzmZXPVdPeliSNtXGxsykVb9UZ5Sf2RSgLyKJ2T0WXygHnQ1P0K/Z4K9VYOxMTsF+hbOFDD5nccGyK7nfXK7wCEEbJ+u9g1BNgBdREdCjjgT93wc5JCtKV1dx/6Uxjl0g56hbxzkd+wcDgRX5rn6SRhXDGUTSa82fhGG/VR9lG5VgjixnxfkIl/GJBYmdCscTtZ2LNLPQ9+4xBhH+yg5m3nbmZe+ei2FzwrtibGSOcysfZd2hn66nHWlXVukKi16RejfHIzbXXVFH6F/Uh7iYtNY6Orbps+VdOavzONm1cMQJHtXHU5jvyL4AJQdm055tJMVXcS6kQxdbXbROmCHLT4AuyKQi3bHbuZ52p3ZGkblrDPAYmDjapOYxhBiGDgY8LsM1VaB8UJeOre2m08DOsBARdmZaHDloIYmKaXX9GBwaw6utt1vh4OkbZDST4QtQJIRo4UOSlu/mGDkk9dPP/20/bRO3DbOggQTFHQ55KrJImHRCfkxghjrIW2RyQB6KL3zlzZdIteRBljd09iFdD7kHcO0EeoGOUpbtqjTeJ+UoD9zLgsX9PE8DjJQbgaHZfRXY8YEk3T6RGlRa1rUv5cx8cIRpCzY61l3BjAGRHvPOIhdrdkJjbc4AaU5A/KU0ES8bxzEtuoKPXLheDDZxQYrbRyk2vjF+Kx5CXVCevkiMudQzkWBHuK8gFvhWAiG2mLBdvLZZ5+1nz6HdstY01cfd955Z9JXaXs0el3keII86JJ6zUG/+bxkGuLYTjloS7SjWdOUw1eaS0fQLwftMF5dhSHtkD6OjMjaRWzjjP9yVN999902tAwybce8QPOfUn+gfVJGOdPTgr2gDNxWwC4p+h6Lg3nblgylW3+RAR0s+tYV+hkHskku7cAx42JUzrqMrQwEBkwr5O+//34yKDJCOHy1+1c0SOMgzUPNOapBvlwhxMBgkFgNrFGSGwhny48eRgKavHWt7GGU6czoqLRajsOoiVsE44TR6DPqopRGDcoSdYhOMALUIauMTKgwZBhyBjvVlyZjlAN9Un7iUd845hrAZMA1eSI+eZK+wkADUt+EVbLW6qZGLT4TRw2E024pol4kDwsUtC10T16xbJBfhWGhBz2X6jSPS/+iXQ2tf67KAAsisdzUEfrlilcJFpqIT5zaBCQu2MTJNnroup8LqHPaSl88Y8aO+j2Li+pj2ACgnfN7tHk12w70IWzQvJMvyRRR/8xBZsZnrtJgW3iwKTLUiHYkwrhAeXUu+TG2dk1Yics4QpqlZ33gaOX2EzRmDrHTebo4jKDxRc9MKY1f11577ca4JVuJTIz5xMF+cU5caJXucz3pe6lucpAlxtNYK9m74Lxpxv0uSo55brOpZ3SWjyX5ojxojEV33AtNOflM+2POmI/5tbZWgzSELpbk9UrdxXrtoySDHDQ5tZSJsZr2D+iIeQSgH7VXkfdF5gD0vVyHpbaihTTaJ4faIfrseoaSIE3Jg8ycD5QTHQG2LLYh7BHzgDjPrUG5NW+JeiD9XA+zQjtCX6Sn9IE8mIvkF8q6+pzqTNA+iI9e4pHHkwzorCZDnDupHen/LOjCmdqyjpi/GQmXRwSvKGgMXnptQGNk06svzrWvQ+A4El71oHilVzKcaV87wbnTwis+moEsnU8epCXI62D72hd+Ix7fGyc0vVaBo5lIbHodQ4S0+Z3zORoHKb1yQgevc6Dc/MarFuB0+95Fwk6ePLnpVSCCV1UQT+k2HTq9dkGvsLj99tvTQTqNs5X0QnxkIRy994EepPNTp04lOUifz8qXz+iIcPInjHPIS7KgA/LUORx8V3kFOqQcMR76UjqCNsJvKjNQL3xHX6RLOGXP84iQLvFJS/VOGOVBZ4SThsIpP/UVw0sQBz0PhbRpRyoT7QFdqJz8pjagdsp/dIxuyQ998jmidsX5yEq5iMv3qBdet6L2htx5OqC2QH2QL/rhnFJcQX6cE1/nEiEt8uRAftoS/YrvyI6M6EbtDd3Efqb2No2ujRkjtHP1V/qVbIDsJv1dNkDjCf0whzj8FsfNodBfOY/zObAVhAHyySZyYJuQg/jIhrz8lz3Oke3R+digOA5yyN5hkwHbojDyqdnyaL84mgnwhtwap7FDhDMOolc+c05Jhzmaj1Bexk3JRXkipJWPX8wV0F0k6kFHrC/Sl50nT9U7eauNYDtle2M45UVPHHxHTsrLd37jey5Pjmw952N7ic8huaPdJ110SThtVbZe+Slc8w3pEj1RZtJRO8/1yTlq/8SNcpNOrHOOqCv+q72imyiX5OV8jSc1eQEddNUrbU19Ev2q7amdEK56Ac6jTRJOuuozlFHpIzPyK4x4kgmZ+Z064ne+kz4yKG9Bm1Sa+XxF42c86Id9xPPQIfUW51HSKTJykC9lJx66zWXM0XybQ3pALr5LD6SnPpL3BbWZaAdq0E6oC8pBudAXdYY+I1GPtD3gXOkCuRQOqt/SwW+SF0oyULZcBsqsORO/Kw30q/aJroA2pnkTR6z7qN/8QHdRNrNcruJPUzGjgdU3VpGaTrKxgs4qT9PxN221YYWNFaWmwbYhn8NKFuc0nbUNGQZ5l1aQm8afVmhrq01Nx+rdBsTK2tDVKspK+SlffiUUOTgirIzlq3TQdPokOytlTYfeWEHTKixh5EN+XZRkRwbOy/OVbLkeJQtQLmSibOTPod8iyEk80iIO8uZItqgXycp5+o12UspDlOqeOiV96UtQFsLy8JIuuWrCVZJSO61BnqzwkpbkRjbyIw/Byjf6aQzqxgpzrU55aCNpNEY+9S/I45baG7/FPAWyEHeofoG2V9MDeasM9Hv6FHnQviRjrY6IK51xrtqBMTsV2jP9lLZNm67ZAMIYC5vJ3BV9nvO5UkafJ52hyKaWIO/cRoiarcjBZg1F4wZ5YiMEYfwWKdkv0NigcRCwFRq7SAe5h+gI3aBz6Yg8sWml8Z94yMN/2doSyCGdECeWKy83Oub3vJyEI0Neb+iJcLUd2VTkkS5qlNoBaZEGv0WQiXSjrEB5pKcIeVNmxrDG+Ur1g4z8J62oA8jbTF7/yIROyIv+EnWNXPwe4VzVY6RUjrxdkxbylOo1ry/g97y+ovzSs8YyQf8lLfKQ3pGN8zg/gjyqK/KLMkGpLtUvBGkjJ3HRIXkOAfvDuToHmUknloffSZcyIAdlGDonoq9KJuRVWaSHvG1An867ID3VIzLGc1QHEWQibt7GkIG2g35oK+gi1sHHH3+cfuP8xrlvQ9fpkgH0myAf0sllI09+I/+I6ob82dXBHDXqi10syIDOctnMchidsz4vdBhe13X27NkrDJYx2wltke3+TJa3AjnrQ7qwnPUV6+7GmAps1eU+yCPZw1qNGQOMXXLWn3tu/bWtxqwSOMPc4llzeHGuWVBdhkPMwgEXNrsuatI/7ayPg9G9um1euJ/s5MmTdtTNUogrrNwPNPR1bcYYsyh0xcaOujHGLIfSczMi7Brg9WnLANm46h6v0EfYCTnkwcNme1gpZ53VWZ44fnDAK7KM2QpuuummdHAlmysHh9unE28FMrJsCxvKNHGNMTsPHHUeUHliznezG7OVaPxiO7AxqwjbzZkHstsX/wTnnO985gGcbDPfyjliFzxckq3vyMaFJW67QDYecqhbiY8ePdrGNsvm/zWNZiX2HzFB+cpXvjL58pe/3IYYs/0w8cAAco/RmTNnJl/60pfaXxYH29lZ9fzBD36wcb8URr+UF3HpGz/60Y964xpjdjZsq6SPf+1rX5t84QtfaEONGReMkTwh/Itf/OLkZz/7WRqPOLjSZ8yqoPvNmavxlqvvfOc76XV1//d//zf5xje+kXyWZaHnVnzwwQeTb33rW2mBl/vXuV/961//+uSrX/1qG9OMgZW7Z90YY4wxxhhjjNnprNw968YYY4wxxhhjzE7HzroxxhhjjDHGGDMy7KwbY4wxxhhjjDEjw866McYYY4wxxhgzMuysG2OMMcYYY4wxI2NUT4PnNVOvvvpqetff+fPn29Dh8Dor4HUJs8Jrb3itSIl77rmn+BuvG+G3IVC2oZBm36tMeC0Xr18Y+soT3rPN+xM5eKUEB6/yolxDyvDRRx+l90Pu27fP72DMQLe8R/Pll1+enD17Nr0qTfAOS17dwbuP0bkxxiyLp59+Or3m7dSpU5Mbb7yxDZ2OV155Jb1+6+TJk+l9wsYYY4xZPKO5so6ziJPzwgsvJIdwFnDScUJ5of+s4PTivLJo8MADD6SDCQmOF7/xn/cR6jcc12effTZ9vuuuuyZXXXXV5N57703lwHnLYWIUz8d5zw8mUvw2RA/kjSM4BOLdeuutqTxMrpCD78j95JNPtrG6QSZk5H2M5nPQy4svvpjqg0lwzvvvv5/0VvrNGGO2E8ZbFnpLY9RQ3nvvvWTTWGQ3xhhjzNYwuvesX3/99clZXltba0OmB8cTx5qrmLPCBARHFi5durTpyjVX36+55pr0GTnjFVQmP+TPFVYcc66wlq6k4tRDTf0sAjzzzDOdV2GZbD344IMpzoULF9rQMkyqWAA4ffr05ODBg23oejkJh6E6x+GkbNST2QwLRSyK5O0Chu5e2Epou9Sfr+4bM26wzfTV/fv3tyGLg3GKBcZ5rojblhhjjDFbz+juWV+EA4iTjrM89IpzCTlayJNvMc+/R4iPQ3z8+PE0GcIR5mp/Tu7I5eCo91314Oo/kD7OeBdswYboqANysKAwDUzw7KhPz7IddWDr6jxX04wx2wPj15DdVbOA/Z536zrjoB11Y4wxZmtZyQfMMYl46qmn0pZkVv/nYVanlPu5mcjgGLGtfVo4l3vRa3DVBQdd941zC0EXmvTpvv4Ik7YxOJJma+Eq2PPPP99+M8aMFXbhcFuNMcYYY3Y3o3bWcUbZVsxRcjK74P51HFSuJC4LHrwD097X13eVHHDODx06lBYlWJxAP11XYe6+++70v6ZL0hkCeXA/fmkBAl2Tvm4DeO6559pfukEezmMXAgssJflwNIkD7CR4+OGH060C5JPDRJd09LkrLrCgQ5mIRx6leCo3MpLWtM9WQA7SjrssyJerZyoXbQSd8Z34JSSHZB3aL7hlAtlZPGKXBfnkO0+QjbojHr+XdoTUQGfIBJTrpZde2khHC2bITr0Qr7brRXWBjinfMvuvMcuAvkofoS/wXBH6kPo5NoI+RP/RQnBclB5qp9Rf4286lwOwQdgDjtL4hZzkEdNAJvqsxgfsNp9z2xeR3ZNNGzL+GWOMMbsG7lkfE7fccks6Tp06dfnGG29MnxGT49ixY22sYXD+3r1722/TQ57kX0Iyra2ttSFXcunSpY14jePehq6jcpU4fPhw+6kM6V533XWXP/zww/T9wIEDKa2jR4+m7yU++eSTTbrcv3//5YsXL7a/DuPMmTOXb7/99nT+/fff34auc+jQoY38ke/gwYNXxClx/Pjxy3v27EllQZeUnfRPnz6dfifsyJEjG3KfO3cuxdd3DrWLGJeyluKSX4RzkJO4yKD8KY+gPKSnMOKqbaoOBHE4X+2Cc0lTcnAunD9/PuVLmGS95557Uhh1G+tXcA7hMQ2+kzbnofManEP9kN+JEyfS9wsXLrS/rtcDadAmyFdx83abQ1yVmYM0SYdD7Q25CFf5FK46FnldSAbaqjG7Bdq/+hR9gO/0S/otdodwbF5uV+g//C57iL3GPjAGYoeAOPRHzuGQnSKu+iV50+/VXwmLaajPK2+lgT3iHMI4j/7NeXwmLrIxDkUk49mzZ9N3/hOXMM7DnhtjjDG7mVE66wzW0anCcWcCwBEdjD40+dBkYlo4lzRKSJ6+tOXcypEVko0JSTyIX8tTMGnDQRdM1EiLyZAmVCWY8EkeHUyG8glUF8oLWQXpEhbrBjmGOFnIzARPcB5p5edqksoEVWVkMkgY7SXmjf6Y7DGhVNli3FhnlAN9RphgElcTSJ3LxFJoMo0+IgrP20UpvsqKTNEpVn6lNhN1BbX8Sqgf5TIrv3xxQItAsdw1pDNkVv2QHmXjiAtt/E4YbTFCftK5oH6GymDMqkB/od3TZyPYCcLpO/Qv7Btx6FNaqIy2UI45jnRE40+0G7Lj/Bb7odLN+6bSLqWBvY6yY2MJj7YWmYmXLzJiB7APsiPGGGPMbmaU2+CbAXzTO7wbhyQdwGvHhtJMOtL/abbzLppm0pH+a5tiTjMp23Q89thjnQ+wA7Yx8wA60Tg06R53tiPWtnpDM8FLT43n4XeNM5vC2K7Mq+bYrjgE6TSisnE/tB5eRhmeeOKJ9LkLZKfMoqYvhTeTvY3PzSQvPSmZuPl2cOI0E9uNchK3mQSmuNqCzTZOtnqiF7Ze6uA7aCs6ZSafxlFO3+Hmm29uPw2jFF/loL0fPnw4fQblE+uENsx2UZ0jlO7Q7fAlqDfaD3JEaI8w5N5ZzgfaViwXBzpnm6vgd8Jj+dA1ZeC3WBdKy68KNGbdhgN2kz6EfWNspJ/cd999yU5FG63+k9vTkh1XXNImHXHnnXem//kYofgRhSGnxmyQfeB1b4L0GLPydLhlC3mxz8YYY8xuZ8c8YE4OXbw/rg9NAkr3220XmuDcdttt6X8OE6N4sEgRndccJjDogMlMdGo0Gep70Bw6IY+1tbWNyRQy4rDPqifyxsHE2brjjjvSPY847TjHfZw+fTo5qpSJey95FV0X+cTuoYceSv95j3mEeHlcLR58/PHH6T8OcC3euXPnNp6cT9nOnj2bJseUkfs09XT9rUQLH5DLKD777LP202zgJFP/WtSIqE1p0WIrqS2osShFXQxZ+DFmt3DDDTe0nz4He4udoi+zaIudWqTDG+3RIpDNWXS6xhhjzCqxY5x1XQmoOS0lcK6WCU6QrmjI8RlCvCKRw+vacOqjo87BFVZ0g9NTcq5yR5yJ0qlTp5IjxGcmTH2OfhdMEpFbTvddd901aEeDrroyscTxJp1pULvIrxyVUHtQ3A8++CCVm7rJF004dBUL0Cllevfdd5PeuhZUtgJkYdGAuo56RS7qfcjCSAktJtUmzNLZNItks6D0KWdfXRhjyuCcs2BKf2YhNF4hHxvYbvq1FqAFD9XD7tDvjTHGmN3OjnHW5UzUrlCXkINa2vK3Heg96Ew64hbqPqJTGScxlAfnDGcRBzc/dCW45HTjQJdANraWwzxXYaLzT5rIytX6mhMI/EYcJmc46dPoSGjxZogzp7jSr65O4QCXkCOLXpCTLd5xm/d2g26ZfOsp8DylmTaC7mZt49JbzRmnrKQtnW0VuspWu4q/1YsFxux0uKWJnUnY4XhbzZg5f/58skHaBYBtw+Zoh4Axxhiz29kxzrocp2lW2zXBX4azztVPJk9MPJg8zYK2kwu9rq3mLOr1azhyuXPD99qVbul0VocMx1z3ypMWTiWTRRxJZKmhq8R6/dwsqJzcr9lHHleOamlxA7m0eME928i37KtU6Jk60m4I7slnsjtNn4C4CwEdkCa6qe3ImDb9WdDOk9J74JGhqx0ZY9afZcJYN8ui57KgbyPvmTNnNi34TrMTzRhjjFlldoyzjsOEAxgHcZwprijXrt4yEWACIKdsGuTYRcdmKMjFe25xgmpXPZUuMpZgcYIrzpKd+DwY7ZFHHknfS6Ab8iJu6f3UuhKboyvL82ztzu/h3rdvX/o/xAl/++2320/r7/8F9I+s+QJDXtc8eAxnMnek0asWeAT6REeKy04EvlN+6kvOKv+50qOdCuSJLNIT3yUz+dQWQRYNMupq0zwOtOSlnZKeHlaonSBC+hj6Dv55oDzUBbKxi0ELJaqLeGsIbZuFrFJbNmaV0DiUL6TpuRsR4ka7FxfgSrZ0KxnaN3m3um7h6ltkYPG7NK4ZY4wxK037VPjRoNfENA5Veg0MRzNRT9/zV7k0g/sVr4MRvNKG32Z9T6teNcNxKnt9TuOAb/xG+vx+7ty59LqdxsFL4chceyWaXpWleJwXD9JsJi8br6+j3EqXfGqQ343tK844P8ZtnKEU3jj/qWy8yodX7pAHcYfqSbKTj+qDdFQWwpCDz9RP3+t3bmlfIcTreqhjdKkwvuu1QDEebQKoh8bB2/TqIFBc8tfryJRu/uo/0lJ8HeiDcgq1ycaxTfWADLyijDD0oHoC5CE8b5OUhfCoZ2RRfrEMvKZMaUt//M/l1EG8IfWn/CgH7SHKTX3xG+kgC22HstAe+6C+JVtsc8is9khdCXSODITH+uCz4uvI64I0CeO3rr5gzE6Gtk0bV1+lD9D21U/pm7IN4vDhw+k3+hB2iriyXfRPjWOxX8ZXIsq2M0bEsQsbQDh2LyJbF+1IlDvaNI2nUW7+yw7kB/LG10CSln7L7b0xxhizylzFn2YAHBVcGeBKLVcFuLLMVdrSA7S4CsvV0viKLsFVaO5/awb2qbbBc9WUFfwSzcSn+hs0E5GUF/9rsBNgKOwkaCZVKc94RZn0c31wRUWvJItwxZKDfDnQLXrTq7DQLw92a5zJ9L0LtiLnV2eaCWG6KkLeXE1RutQZ+uK3LpCHbejUH1f2kYcr2Fy55oou5Ydbb701lZGdCrQNrhqRBzrK65640ExOU1zO46pNTC+iOkd2fufJ4+gswhUdfmcLvbb4c3UXeXUFPq9b2gL6KYVz6Eq9IE9kKemY+OifVxfy3AYedBevXtFXuELe175Igz5DnedtiDqkjOgLPaCvvqtdpf6ifpBvXSecusrLjRzqM0PqgjLycED6fV/7MmanQv/BDso+0z/pmxFsrOwf9gA7xevRsFPYDfoTu9J4HRr9rDRO1Pol5yMDaURK42Ctz5Mn9qwmN+kgL1fXNXYAZcGm0cext8DOMM45fvx4+m6MMcbsBkbprC8CttcxsOOwmZ2PnPUhzVXOOgs1qwJlZ7LKYkUJJrZMyrn30xhjxk6fzcLxx4E/0T4A1RhjjNmN7Jh71qcBx4arAazKG7MKcN92aVeAoM1z9cwYY8YOV86xaV07Y9h1ZZtmjDFmt7NyV9Z1BRJHnW15ZjWY9so6k8EPP/ywDdn58O5kJq9sTWVbrLa+Altl2WrKFSpvCzfGjB3sM3aa25mwaTw4Ndoubvdhwf306dNtiDHGGLM7WSlnnW11HNzjZqdlNcBBp065CgNsieT+Te4VzyEu913qqffHjh1L95OX4u40mNTyWjOeNxDvIaVs3KvOhNcYY3YKLD6yDR6bhr0W3P+O7c6fqWGMMcbsRlbKWWfAt5O+WuCAc0TYDl5z1ofG3cnQzpno6qFsxhizk2EBkgXJVbPVxhhjzLys7APmjDHGGGOMMcaYncpKPmDOGGOMMcYYY4zZydhZN8YYY4wxxhhjRsbKOOu8k3WZkD8PNsv59re/PXn22Wc3PUCH+/NeeeWVydNPP92GGO5XjDoaAnrkgXKcK/J71o0xZqfBQzUff/zx9JaHacEGYhd3E4wF8cGbQ0FPccwgjWnHIbNc6CvMvfgvqEPmXvShITCHeO6559I5OwHabF7mZSA9M8fdzXz3u99N9RHnolsJ9Y/OyXe7wDZS15STvuK59jbDPeurwIcffnj58OHDly9evNiGTM/a2trlEydOXL7uuuu4jz8dhw4dunzhwoU2xpWQ38GDB1PcW265pQ39nNtvvz39hnxw5syZy/fcc08Ku//++1PYVnH69OmUh8qyd+/eFHbp0qXLZ8+evXzgwIGN32IcysF5lF3xczhf5eagTJwTjxtvvDH9du7cufasOqSF7oeAzskPWY8dO5bkpM6of/RtjDE7EcYJ7NmePXsG284SJ0+eTOnMA3mThmw84wLpfvLJJ5fPnz+/6Tcd2GTsPvYfm37q1KkUP0fnq5ycl48fGjtJow/GgSNHjrTfukHHjH2U5+jRo2ncQGbkJV/mAWbnQB3STmgDwByLeiSsNCfLoU0TL6YxdpiXIS9td1kwB5Se+b+b2b9/f9LDrPZ6GmijmlsPsY2LAB+AOqZvYbvVX+g7ZntYGWcdmBQw6Hc510OgM9AQp3H8iF8aGGjYGNYI8hF/Owwcji15ceR6oQNqYSI3MnzXogJ6oBwllHZpgqMOjlHvgskTk7Yh+iYuhiofpJBPZTHGmJ3MIiZ/i3DYQROzfBwDjRH5pJGxRs489ro2Buj8WjlJo29CyDhDHowhpYXlCL8zzqDfGFdzB2Sxs76zoO60iCSYJ1CXQ5x1oP0Sf9HOOm1s3vloCdLl4gblXCb0FfS2is76NBf+0MNWOa7UcW6TyAu9b5ezzoIYtlow38beTlvmmh9h+lmpe9YbZ23SNJ609WmerWyNgU//mwlA+j8PTQNP7/qOIOd20XSo9tPn5RL8VpOlMb6TZgKV3t/Na8IeeOCBqbdkkn4z+PVuDeKWAOqLfPq2b7INh/Qee+yxNmQd9NwMin51nzFmx7OIsefw4cPJprJlcR40bjRObvofqdnbxvGdNBPJdGCvH3zwweKWzVKaEcbzvu3t3IJGHowhjCVdEBedPPXUU5tkZxxkvFuE3s32Qt3R1uNcZtp6zOdGi+L111+f6VaWPmi7R44ccXvdQqbZ2k/7oQ1uBcx58y3n2z3PpR3HPsJ8+9KlS1OXuXSrsBnGyj1gjkaEAXvppZfaECOmXSTAIDBZYkLFROjhhx9ufxkO9bF///7225WQ7quvvpoWBeDll19O/2u8//776T8TrhyMyYEDB9pvxhizu2Gx9Pnnn1+IwzDt+AHYddl2xo9pF9EZg/omhIwZyuO1115L/2to3HjnnXfS/wjl8/hhFgUOFn3P7DxY1Fv2c7AAezWGNkRbnneBgIXUrVi42i2M1lnnCitXBDimfVjOvn37UgMvOXTbDY38hRdeaL/VQVbKqSOXnSsHrG6hD/5PO+mZFTroiRMn0mfKMs0DTSgD53et/mIQWQwgD+Jy9aXrSvydd96Z/vNwvlK7oO6NMWZVwNbL9k87FrJDCif0xRdfbEO2n+PHjyfbrnIMhXGAq+pdiwRM/hiXuILPOMP3rocuccUfWMwvycKOraGTUsY36oS0qJdSepQZeYjHZBVZS+Tje2k3AenIgSA+6RE/jpeUH3m4GldKg7j8rrZUyyuHsmrs5zzOr+UBlFvyES+fzwjOVzzKV5KHMvE78cg7d6KUV5cjgN4pN0etDrpQmTm/VpYIcVicIi8uMHB+fh7lVF1QpliPQ0BXpBshjTjfpM5UBwJ9kR/hpflc7KdRxi791lB7rOWl9qg675M3L2+EvCg7R0lW6oI0BGmW4tIOH3300fSZ/DjyNpmTl0NQHpWF3/hMnkPqWm2I8iMjctTarvSW941IX12UIE+1BZA+3nvvvY3PMS1kVnjUK2nogdr6/T/+4z82PnMIyqiwXE5+Q3/oUjrPdYIMsikx3R1Pux1+NHDfEQ9/aQb4dB+bHh4y9OExwP1xnHN4xodv6P6lae7DIf4t4f4o7s3QfYcckdJ9ProXm/vpeIhDvJ+O7+gEfXCfUjOZSHkNuadGeeUyCNLht9o9g4AsSoN6iSg8v6cGqLs+uE+Q8gH1VcojIj0pX85Z9n1bxhizSA6193tjG3UvdbR508DYwZgRx5RpYJwi35KN1299906qDMgSUTlL4w9plvKMcD5jIjBulPKIoIOoT+L25VGC+/d1LuMwn+P4D8xlmAMQlwNdUQ+lZ9gQj3kL94CSDmOcxnfKp3Ga8qIXyqBxkN8YA7nfmvnDde2zW3hgXgRZOY//yCZ9dZWfvO5pnytA+hx81kHe+TyEuQ9yIDf1Snul3HkbkTyUuyYPYVHPyBLnTcwLVd48fclH+uQvmYmfP0MBOfmN8kWQSw9KpC9qTpfHy5HcxOU/8TXPAbUH/iMLn6nPIfe3M69S3UsO6h85CePQPFp1x0E9EE5eMVy6IA3iSJ98V7vTkc/pqBfCY50IZCM+ulU/RybI5VUfKslLGynJK+jTxKW98Zv0Lp+BtONcPKZJWWkb0rv6kcrNZ45aH8nLoXjUK32AMHRD+tSZ0iXvLigT+SIn8dEf32UnaY+E85+yk5fahOxhhPZIvFgX6KRvTCBP9Eh8yiF9/Ou//uuGDJRJoGt+V/wYpnalNP7pn/4p9Qn1TYEOsYMx7bwOsTHR/gnSRV7KyX/SRo5Zx74xMTpnHcWqk4loPIYgAxIrcRrUCNXYhlDLTx02UjJwGDU6Ud6oaKR02Bg+jXzKK5dBIDO/yQjUUDxkjCht6kydkAPDQEfpAgMWdcZ30qITdiHDp7xpHxgjY4xZBTShYlKniSQTGE1s4sS/D6WVO4lDYZzhfE1EI/qNMakLTWgZyyKSjf/5+IGNL+UpmA9g+zUv4L/003Uev2lc5uAcxt9pJnTIFsdMzs0n4Ewu4wOVcBI4j/wks8KivJyT64q6Iwy5aQdAntIf9RDDpe8oI05M7mwhY5eugLamPBjnmZMgoxwJOWCgOskdBjlQ0dFCduo5QliUB12p/QPpI3OEMpF23gYJ43xkRs+cK72g81jf6Ilw2l4EufO5hcrdN2fSPC2XS3nFciKL2kYsbw30W5JXDg16pZ6AfKgT0iZcbY9wwvJ5q8pHXOqe+OiAMI4oH2kQls9FaYt5mHQf24bsB79FeaWLvByE5TZEc+eInPto8zSHVXsAte28HUquoSg/ZBToiTDyjWUmL8KH2GP177ytRR9Av1Em7AM6im2bMub6kQx5+ymhOi7FJTxvP7U2If3n1MJLace2SRnRg+xeqZxqt7lPuRMZ1TZ4toiwbeGRRx5pQ9ZpKiM9pK1phG1IN01HT//ZHlHbNrJdSJYueCAe2zqahndFGdnO3zTYtB1EW0P4Dnzu256zKFSOIdt3BNt3umBrJg/6EU1HTAd5dG3nIU5jCDfuU0QHPAzkrrvuWnp9G2PMomgmGxtbt5sJSvoOfc/2iMh2v/vuu+n/MtCYNXS8apyL3vGD+QLzApWP/42zkj536QdZGD+ayedGPmytvOOOO4rbZ0tQDp61IhkZt5944on0Gdj2yXZMfte4TdrIqDBg3CKMcUvx+J30iK/xVmVsnIKNe/iJo7lSM0nfFK7bweJ4iMyMq7EOkDmfc+SgI0BvjdOR8kIO5itAmsqH+Qrpqx4Euob48F/OYctx3B4e5aHsxI3PIUAP+cNlb7vttvbTlRAfmSkDnxsHaWOOEbf3lkAuyka5VTccqou33347/Z8WtgOThvoEUOZnnnkmlXfIPcqyCTmSjTkz9QTkQ3zSJg/FUTj1ENuE6pu4Bw4cSPEbh3jjeQ59toe0KANtJOpN5Y16Uxh2LcrbOHpJ3lI5Yh9FdrZCc3tkzEv6eeONN9J/UF5qD0CZ0H1sg7MgGSOx3zTOYvoMDz30UPrPVvJ5oS+gKyA/dI7eYnl4qBt9JOpHss3ahpeF5NbtSvgAsnvY0ptvvnlTOWVLsDM7nVE562q8MiaCARkjq4rqgwpS3GiExgiDF2CUSmCYKENsgBwMfhx0zO1Ag3FtkMDp5h4RHZQHA1+DwZIOpI4m5Lz3PSiINsJk4eLFixsTA3SFwz6v4TXGmDEiezmNjbv22mvTfzl+y0Dylia1wOQrjh9M3rUwUQOnITrIoPEDR6xrbGSOQD5ra2sbi76Mcbz1ZIhuGXPI4957791YWFY6oIWRfNxmos64rTkOi/DMVfJ4OEpDxndNRofMA5jIUzYWJXBwOEfO2BCYCEeYC8hRkAOFLihPXs/E5aANSr/oAp0zZus+VGSUPPznHGRFz5pwMx+cB7UZPay2hu6XRd5YN3fffXeqG/5PC+VHV6V+IGcYHW7XvE7tpzRPlnMr1Leis1yCOqWclCHq7eqrr056G/JcIcmVk4cjC/nkc+QbbrhhcF5D2/+iUBm20h6rPlUXem6CDtVFfmF0p5DXGeWln37wwQebykn4Ti7nJtor7KNAW3jiVpJZaQxNSituQxtK3GIyFOKTZw5p5GrWNpFmIErnNINbtcxNx75ia8c0KK9cBiE9dW3pYnuN0si37ii8JL+2L5VoOlDKG/3kB2WupVmDOtN5bKkyxpidCjYfW1ayyxozhqLxjPF1FrDJNXus38iji8Y5SfHybdhd5WT7rbar5rDlsZmwbRo3dBBOmifb7ZFDIH+NhY3D2IbWQS7NVzgYy6N+GscrpdcH9ThkvEI+8snnArVw1XleL9oyzoGe8vt/SygPxuycw+12WuXD51rbRCf8HucQbA/WuM151GsEnVIf/M5B/eZtolZWwkp1oPLErbGlMkpXtTbYR0ku5UM5ctjWy28cfXOfWp2oP+WQXyndUrjCcuiPhEedch5hsTzaWj6kbUneXK6+cgjaD9+75pqiVi7KE+WHWtwapXKUdAOqu7zPllC6nBOptfk8PnXA97xfTYPKUer/hOd9rFZu4hGeUwsvpa16yduLbjnI9bFKjOrKemOs0//ayp1Wi4aglcmmstP/MUJ52TGArLyHtrSayipc/kREUYq/FWi7GKtZWv0dQu0qCnKzhbAxIOndtvmhq0fEyWFLT6ncjZHa2Ja3CltejDGmBPavZltL6ArOssZCxnOuejCW5VfCu2C80Zwgh6vq7N4qjR9clYbS+MHV9NL8opkEprEYGG/75hrI1UyE0znolTS5QixdU1Zd1SqhMYx4tfnOVozv7FbQbjRkY97Rtx28C9WP2iPlQXcl/SlurFO2B3NLAvMKzuHp11EedHv+/Pm0dZn2wNUy9DyPbnRu1/Z54OojaCdAzjTzUUEZgLaRg+5Erd0vE8mkMtRQObajXfflNUsdrRKqs0W24TGidlC71WsrbOl2MypnXcaztAUaB6zmtJZgIKKh9hmWZcO2LwZQOpNeFxFhsOI3bbWL8HqCktFfJOiRe0EAZzgOKEPRlhRBWSg3W9xKaELHPYl5J+N7zTCzPW6Mg5wxxiwC7B82Gfs5FLYGQp9zslWwwAo4XLMsGDDG4WQL7D+TzNrCMYu9jFPEi+OOqC3mdo1JORqPGXNwfvmPTHpNk3RdemUecskhxcndrvGdreZAniw0sFgOpUWNEp9++mn76XOQD11Lb/pfKg/6IS4LIyBdIQ+y5PLQzjXnw6lHz9Q5eZbSH4p02teH1FZLdYhsbM+fFsqKDpCh5kChnzHOY6S3vj6ihRsW1EpOktrhIlBepToib9me3UpfXWhuPyuz2POcRaShcmJT6Js585ZzDIzKWdcgiyGOgzNGDWXLyAODXW1FWEZFFbhdlDrDEBiIGITycoMcV+5tzx3ed955ZyENvQZ61BV/Jlqsxk8L5+Z1h+HouoeEemNAoNMxYcnhAS0lXROfCUEuJx14nsHdGGPGAPaQBWhdPQbsnu75LaHJyzLGQ8YtHC6eX6IdUyVKEyzBhDs65owfekhTCeYQGgOIm0NYKT/kZczDietzlmK65Mf4yH85tJrL4NDlcxl0ovKoHgmLYxSfeTjWIsd3LoLEciMDbaLWbnJynaEv5iTMXygrqDzoJ47RfKYdSC9A+brk4Zy4kECdaPfcUJlLkCY78fqcThZg6GvURdzRh8x8J40h6DzNS9UP8kUSLUzEh+7Oyjz6EZJXsMhF3R07tv6wwBq0WeoSPfEMCNUxeohtfwh95WBeST2yAEbais9/dml02YlILR/pINfFdqGLjZJvWjnoM7Eu4vnMy++77772Wz9a9I0gH2mqjUNtMVRlyfuDwuPildKo1UspHDtE2vlzRygnzzAQ5Mt4GWXeEbTb4UeD7kHhaAzDxr1u+T0X/Ea4XkMR0X0a09yzFtG9Sk0jGnS/UrzXKMbX6zgIj/dYnGvvWaFsgnI0HSuF5/ddxHvjSI+jMYjFsucoL45ch8iqPNE7cZGZ/9yfwm/IWLvvX/emcDQdJZ0XD8rRGNJN9+YQVpIlR2VGhng/ku7JaYz0pleIEIe80EusA8Il4xB9GWPMssH+ys7JbmFTsW/5vaAar5pJWRuyGewiY8YsYOM11h7PXmHFWKHxGRmQD9vLf8YTfiPfXF5BXMrD+dy3rXFDB+dRJuQXhCEP6XfROEQpXeKSlpBekY0xSLrlP7pmvMnvhyxBGox5gjEyH6viXEZ58j9/7gvpKA7yopM8LY2bjIsR0iI8r3vljR4E6XK+xkfVbT7fyEF/ki/qErmpG9pBRGM0/5UXctxzzz2b4qJvzo91gDyat2l+Eeua3yiHzgG1/7xNqG3FdovMyBHnCEC6xI11CugXmfiNo1aHJWhfOod0JQd5U+6YDmHUTZwrdaH6pd9E0CnheZ9TfrH+Yv+NczylQdqqL/RNX87LzXnEJZ1Yt7Rd4vObfkePubya5+XzQckbyxHlzed+9BflpXNj2+dctYdY95SLMGSN8kebiswxvxLSWSyH7qPOdaM+m/flEmpDlInyqK/KZiBnRPqMfTqvC9mXqJ8uJC8y5Mie0qf4jL4URn0jn+yY7AJxOKRT2Tb0xLnEUxocyKm4qtu8rwN1qfbBQZkpZ65n6pPf874+dv7fc/ml3CXDqjbHf//3f6fVkV/91V+d/OVf/uUVV0t/8IMfTL74xS+mVcovfOELbeg6f/M3f5PuXeDKe/5bF6wSs9rJCmfToCdf+tKXJm+99dbkf//3f6ursKzS/NEf/VGShXPIt2kg6bc//uM/TucqnPTIgxXupiGlc3hK4y//8i9P/u3f/i2tXBGXp+IrnLS++tWvpvRYtf+v//qvya//+q+nbWyk1wVVi/zkJRlIG/2ysoQckpv8uFL/ne98J8ncNPrJ1772tRTvl37pl9oUP4crBmw94lwOVu44Px7k1XTYtFJMHFa4/uEf/iF95reSXlkxI95//ud/pnjIzjlAXF418Sd/8ifpM3X1m7/5m0n///7v/z758pe/PPm7v/u7VCbBZ84nPm3FGGPGTjP5S1dEsMt/8Ad/MPmrv/qrNCY2E6crbCZ29J//+Z/TVU3sdgR7yk6kb3zjG73bfnOw8YwRjEHY4h/96EfJrpM/u5WQSeMb9prfuFr62WefpbGpmXRN/uIv/iKNYzmcz+udNP787Gc/2zR2cFAmrn6wu4w8ucL5Z3/2Z2k8Qi+Mvegph/GDK22kS1zSYnxi3GT8RS7GVMZGrpAS/x//8R9THn//93+/caWnC11l+tu//dskE+MZdRP1j76R7+OPP076IV3us/+N3/iNNsY6zG2QlXiUifMYx5QWukKvlAV9EwdZ2WWB3OgaPSmcMZtxkjSZL9AGSBOZNafhyjd1y1iq+UUN0iUueqOcjPvME0iLMjPGR2i3lJX6Q7/IzpPTv/Wtb22KqzkOv3/zm99M4zRt+Ld/+7fT75Tpf/7nfyY/+clPUhzaGzpCN6oj2ig6oKyUL84pmsl4Cifd3/md30n/f+3Xfu0KOdAv5UG/tJPYrn7lV34lzSvoe4TX6rAE9UdfQP/Ioak2eaNLykb7QUfU12/91m9dsbOyBPJSh8hLv1G9046Rn7zoq/xG36W+aAeEo3PC4fd+7/fS/Fjx+U/5qGvS/PrXv57msHwnv8ZBmnzlK19J5wJ9jHojD/oxczBkIg3aBu0KvVF+6oXvf/7nf57yzOd51J3k1ev/Yjkgyks5ZJfIq3HAUtugnMT53d/93cmf/umfpvMoC3NE2SrN0QlHfmQnDeSnvvkNvwOZSA891GynyiG9cw7547tQDsKibvBJ1GdjX877kFAbQg7aLnNY2jxlID3COdA54apH5CBNzicv+hT6QU7kQ1/URR+0R/oNeZEe7ZT6UB9DL9QxV8J/4Rd+IfVf7Cz9lXn/7//+76dzFRf56Nd/+Id/mHQMKj9pU1bsPfJioygvcZGZnROg8lHuWC/omTZGGpQT/dJe//qv/zqdL5AfO3bs2LEN2XYCV+Gxt59XBl5NwoDBveDGGGPMboTJIc76hQsXNhwcY6aBBQ62ljK5Hdm1HbMFUNfU+Qq6BsbsWEZ1z/oiYPWdSQkDizHGGLNb4eoEVz/tqBtjjDE7k5Vy1tlSwuTkzJkz1W0lxhhjzKrDVVAe5FnaKm7MtJSeBm9WF7YSG2PGwco469xnzlV1HHXuOTHGGGN2G9wTyP2LOOnct2vMrHBPLluigftS7cCtNtyHzkUv4N5417cx42Bl7lnHqHirnzHGmN0MDhY7y7y7zMyLHPUID3Vy21o9mEPHV14Bc+r40ERjzHJYyQfMGWOMMcYYY4wxO5mVe8CcMcYYY4wxxhiz07GzbowxxhhjjDHGjAw768YYY4wxxhhjzMiws26MMcYYY4wxxoyMHeOs80oJXkfTBU8u5Um4qw6vqevThdleFtXu9NoUY4yZFsYGXt22m1jU66X8mqrhMN698sorWz5ekf4LL7wweHxlDui50WpAf6QuV3lOz9P36UfzID3tNru/2xj90+CZfDz99NPp/y233DJZW1trf7kSOvWjjz46eeaZZ9I7ZmeBBk/neeeddzaMBO9tf+ihhyaHDh1K35cF7zlFF3TwPl3sdBikX3/99cnbb7/dhkxSmR955JH06hh+e+ONN9pfroS4991332T//v1XvNIP48b5sY67OHfuXPupzoMPPpje8T/klTa05ccffzzJQdvioL0iL2U6ffp0G9MYY4bD+PXss89OHnvsscnevXvb0OnAJsr2yj5iQ/ft2zc5ePDg5M0330x2qmY7sWeyvaXXPvH+5rfeemuQ7T1x4kRvORjzGRcOHDjQhtRhXHnyySfTWMo4gg3G9jK+v/rqq5OzZ8+2MU0J2hf6o33wmbFx1rlWF8xxmOtQT8BchzG9xm6aG+0WmCNhK44fPz45evRoG7paPPDAA2mBaZ5+JD2dOnVq6T6K2UJw1sfOpUuXLjdO0OXGCLchdT755JPLzSB8uRl025DZaDoPixjp+PDDD9vQ5UP5kGmILlaBY8eOpfI2k7425HNUR81EMn2mnTSDdPrcGPfUZjhIg99yGqe4U5cnT55M5/chORpj2YbUuXjxYkqTtAXtC3lJozHYbagxxkwPtq5xlJN9mwfGUGwSB3Y1onGIg3z4zoEtbBzsy43Dnn5rJo/F8RMZa2nDhQsXkl0mvS5IG3tKeftAPsYKZNJ4wH/kRY7dMqYugsOHDyed9dXPvOzdu7faRnKI43pcHc6fP3/5yJEjac60bLbKB8DGUsbS/HQo0tOY/BSzeHaEsw4Y4KFGmM7NoDxvJ8fwD3HWtptpdLHTwQGmHkpObN/grAkfcZig5cjJ7tJlbbIZOXDgQEqHiUUfxK3Fw2G3s26MmRdsIw7zPGOg7CtHCcZYfis5UthMbJnsK45yjtIunQ/Y/j5n8Pjx473pCC38lnTCpHm3jKmLQLrcamed8XdI3Qriuh7NIjlz5sygCzHGbCUr+YA5tt6xJY7tcfPC9j+zM2H7JFuDgG1CbN+cFrZgsa2zBtsoOWgnPFeBo4uu5yo88cQT7SdjjJmdxmGZHD58eCFjYI09Hbf8YA+5nQfbydZztmpOC2N41xZ4tmG//PLLabs98LmL9957L/3HXueQxqzbUI0xq4luKzJm2YzaWef+I5wbOsy0cA8bjhPn7zSYTMxabtD56K8GaROH+6e7YKIl55LPJbn4nfC+exCRpy+/RcMETPcyPv/88+n/UCgvk86uSSkTRJxsOdovvvhi+l+DySfp8tCcHCbY3OtpjDFCdpf/08A95oyBsyxSLgJsJ/ecAzKUnOQaxMXR71oo5T5lFuaVh+6jrqH755l8l8Yq9DUU1YnGw1rZNM72jY0as2vwu/JQ3Lysyqsmi8ZpydM1Pyih84e0w6FzL+YDXTLnIMM8cwhkn+V8laer7KoXDuScpr9KD5xXg/Ti733xa5DOkHPjhQfKFr+XID3SHaJfydBX73mZRcyD3/vyVN/gGArnsMhY6yfkq9+Im8dTGfv6Gb/nfRnieaTVlU5NT/EcdL0VejLbwyiddQbdO+64Iw3GNBo+lxpiFzw8BieLh8ZsNVy1vemmmyZXXXXV5N57793oODyIhTAOOj3hwH8eSHbNNddsenIpHenhhx9OD7jD6eN3HppS6sgl0BcPrNDDgdAb5+fgKJIPHZlzyAdZYz6kgYy33nprMtLISXqkH+XmvOuvvz6F8780MSSMKzykiTx5ubcaTcIoh+pgCH1tB32hPx66xFUs2lvfpJRFJGDCSB3kcZ977rn2kzFmNyMbjI3hgW7Y4tIiXw3GQNiOMbCGrnoD5RjKkCcks1D61FNPJSecfLClXQsTsr2Ms3fdddcV8mDHh8B4j/1m/HzttdfSuJdffeM37Dv1RRzmB9Rlbu+RhXCN+cwVSEtjMTIydnI+nzU30jis8Z1xg++EEzdvJ8yj5HgwDpIGxxAYM9EXi918Rh4eEFiC8iADsiof5kR5uZkfEQ/dIFOca5RAH+SLrkmP/+hiKNQZ9aG6Q1dDxlrlS92oTsmbdCLITTz0o7kX5esj1wN6Rg+xbeZzMfJWXdfmXCWoA9KhLKpH2kp04AhHP4TTtiQf35EN3ecQh7alPks7QVbO44hzUOKiQ8nAebkMQPmJF9sE8tOuCUOOvE2QjvqNkGzqn9QN8SQb59dAbuWNvMQnf2SV3ISjfz5T56oL4qm/qb3FPomc1CNyc576B/+lf+mIOJS51KbytgFRT8zPYx0O1RP9m3hD9GS2iXY7/GjQQ73iPUqEIeq09yLxUDLSmvXhDdPkyX0txOdBDxEefEN4fp8c93zxYBvB/dU33njjJln10DH+R5Apl4v8KSvpCN1LHe+34TP5xPuweUAF8eL90sirew55mAyyIhvpkw8HcpFeDM/l4uFD+T3aSnfIQwBJP5dN0Eb4ra+OVD6OeI+d7llHH3yOB/VYyjNC2WJ96/467qOsga4UjwOd0RZK93QaY3YnstPRLsieY+uHojFwFvsi+8pRArvLb333E5M/8fKxUWljR6PtZbxH7i70PBKh8bfPZsd73DkYn6e5r5+yUp5YZvKOz0TBxiNbHGMlH/kJ8mVsjGM+OiKexhDiqN75TzjxyZ/2QXgchxXO8wpiusgT2w3pUo4+KANpxTGNtqS6p76E0oxhxEUejqiPgwcPbpKR/3zP5woaK6lX5iCUgXMJ44jzHSAstgvgHHQX0QPy4oNeS+je/FjfyEhYhIca044F8fvaMFA+dCPQUV4G0tKciXLEuVgetwbxkSefS9IeqTPNxciL+iNd4tMe1T+kM9paBJlivZEXZVK6qiPCidcnAyCH2r3aE7pBFsI4kEe/qd9QXxHSyOtB9Ud9MTfsQvPPWGZkk09CvVMfHNQR8kl/sW3JD1B+9Avicj7hpAlR//xGW5f+pQ+liz6Jr7YR9aQ0KDtpKN9p9aR66dOT2XpG5axrYMg7M42S8CFGKaIOokY8LZw7NE8ZqDw+BoF08jLRMThH0FnyDiRjTNkj5BHzIR2+0ykjdDA6sgyNZMwnTSBDEAd0DVQxDGQc8oFShkeDsvLLz5cBJM8+FJc8czBU/NZXR4rHEQdUGTT0S1l1MICSZinPCMZMRhZUX5Q51m0JykW+kovPcUAwxuxOZDfzMQM7ik3K7WkXGgOj3RtKtJslsJH8Fm1gCcWLDi0obcYj2V4+Y1f7bLoWkIV0Rnr5uJTDuMj4q/w5cl3XQPfEz211dGaRKx+LkU95xcl3LAMwMSYOZRFyDPK4cmTz9qCxPE6w+Y7OIrSNPigHdZGPZ5r0x7kV6UW5BXITN9Y/dcx8IcL3vN5VxrxO5TjmeiYsT4O8oiMImlfwWxekn4/nkinC93xeleu7BGXOZSC/vAz0DfLI253mXH2oDtT2hOYs+Xy0FKb5UiyXbEReD6qf2DbVjmsy5HqWzPn8Hd0QHu0OaRIW2xgOMWG5bEo39tkaaie53qWLUvtROWObxb4QlpdFbSm3oYRh66M+ZHtoCxGlkaeNPqnDuFArXU+jp7joYJbHqLbBsy2E7Rh33313G7LOnj17Ou9dq9E01vSfrSRbDTI2HSDlFe/30PYWyqatJ2yjaYzspnuhCeMBOGzN0sGWmqZjpq1++baVCHly3HbbbW3IOuTRdOCNdy+SHvJce+216XtEWwRL7y7PdU+6kIc3hiH9l6xsyyG/d999d1O5kJVy8W7b7UB1AI2hbz99DuWI8jWGedIYtU31k0PZSCum1xjupBvyi9vYSlAnzQCzUTfahkT+xpjdC2MBNiS3540Tluw5/4eiMTDawO0G2wY333xz+p/D+Cbb20wQk+3VWFKC9Nj+KdsJ2Go9N4QtxV1go8mjmUBv2Hi2jbKdtGuchcYhTedgqzk0tyAtwVZbwlUmDtJnzONQnowR+dhI3RMnPmxU8fPxVvOkPFzfY1maiX/apsyWVs1PGgc2/a9Bm0HPjGuSQeRzCOqE8pTGV7XXuG39/PnzqS0D5zI/6mqjeRlpM9DXrvmdsZptvVHPmoM89thjbcwyp0+fTuM05UeflEHbjSPoiFv72Lqt3xsnJ/3vAh2gC0AP1FFXG8z129VPIprX5edrzqLbIyLYjljvOjfKp/afy3zDDTek/zH8nXfeSf9rMlBXce6c13lOTKekB9kd/RdK9+OPP07/5wHZcw4fPjxpHOCN3+gX9OtpoXxR/336yOFc6jCeV0qjT095uFkOo3LW33///fRfE4xFIYOy1cjwa7KAoWLgpvNiiOTA8XscJOgM/M7gGweUeOSDZQRDOwQmBlBKa5pJ3dVXX91+6kZysRBQKlOcbG0lcRAaOrhhqLoWE7hfEl3pnh4dGpz6nkwM6JyFASYDMuzc79Xn6BtjVpeSMzAvy5pwYSOVd2liW6PLicKxwz7jGEXbK2cgLozXYAw8fvz4ZG1tbeNedexu30NIOU9OGPlwX2i8JxcY95hol8Y8Dn5jToKMPFC0FIejj645QQ5lZbzBGUJXLEz0jfUav4fMxxS35AzIqaK8moshO+2Ce2pZ9GBcjs5XH8Qnjb65neRiLC/p+MiRI+n3LpCbOqa9Qakds8iEnrggwr3dxB3S5ygD9YAO0AVpl3Q4L9gU8iq1Gc2JpKtpUD3k52ourws7gMPaJ8MibR/1wUGa0R7o8zQPlJwWysjiDfeIU79RD2Ojpie1Xxb6zPIZlbOuwaNvEBmKGts0g8A8YHDolKy+0ugZ/HFUtUrOg34Ip1OUOoAM3LTI+PWdr3ilFcWt0JHyW6QBngUWTGDagZBFlhK0TwYeXR2IB2EYPiZFpXKXHqxHu+FctQlNOo0xu4+h9nwatsIBGIIWHsl/mgmrHOgSLISeOXPmCtvLwVVcxn0c6ZzSQ+uw1Vw91ZXxIWMVi8w4+Vpsxqbj/Arqr8/x2Yo67gLdI7OcSuoFp7JLzmnmYypPX7nVDtEz+eMwUZezODPkOXQBaBZHFCQnV4rZiVBrl4zd0i9lxGmPDw6rQT3g0KEH2uFWOXXoirlnaXFDO15msRHqP6Sr/oXOmP+gizivpF9uhQw1KDN1Rp56cBr1gf1gkYZdMlsB5dTiITYJOzH0AtcyQE9cNIp6oo54wB27T7aqTZrpGJWzPs8KXwkZBaW7HXBFgEaPscY5x7gzoNDgMcxMIvIVPQwURg8nv2Tch26N0jb3HDmId955Z/pfmpDovEV2TMlVu8pcclwXDYMGegEM0iwgZ9Q/dVi78oPh0ySu9BTm2lN0aQO6FcEYs3uRAyJHNyc+VbiPZYyBgjFFV511ZXdamAvE8Qpbjq2sOWmyyyXby86ykqMAzzzzTPupG86nXIxt2hXFZ+pK8xa+I7PGnYjioQvGCsb20pg9TR33gfNAvuSHk6KdXOTbdcuA2gxl6Zp/AHFJX/opQZ7UHfLgoDLXmOaWjghpcPS1a81BcDxKZeibg+hqerzNoYSuGqNfnHacd/RQWjQSyE/6OI1di1OLQP0lbjMXH3zwQfpf61N9ID9zHspLeWj3LMDkuxaGyLDoq7i0D+Tjtg12LzAXZRGBY6tghwR9hh04tImdAHqPesJ+Yt/YfWLGwaicdb1jmg6FIRtCl2OvQUMGexr6BqcaGC06KNvpKI86q66uM3mRMxdh0CJPjF0c7Cgfk4yuTo9BYuDjfK2MCRYAdC55oAuMZT6gMsgSL94rJ2p10ReOcUY2DBcGLOp0Oxx1dIfhAQbbWQYjZOfKvHRIGWifpToUcroZqEt6Ll3hAeknf9c6MhhjdgfRbuaTfSZP+Xg2ZAwkvUUT7XkO+fK6H8YCxp3aLqUuOFdbpAXOZZdjTV44wuiuZDfz8TGnb4zAfuP4CWTTmKl60GI8Y168V5XyMHaoPEyO0WE+5nMOz6/JqY23fXAesggcZt2vno9PEeREl5S5b7xmfFQd522W80H3mVMvlDuf0yCn4na1LSCP2nwlgvzUaWyPAqey675lyYO+IpKN3/U53j5BfBanQE5oCdoL50eZoBTWR1986b504YT6YP4ou9Kn+zwv+qhu4cRJ53/pos8QGea1U7ls9HfaADLhfFIv9LuhqO7VT9Q+uyjZ488++yz9r9VTKbwW99NPP20/9TM0P/SkW3L69MS5XXbDbBHtg+ZGQ9NA0hMIG8ORnuC5traWntrYdJoU3jhdG0/2VFyekliC35rBu/02HXpqYjMgbDzdfCiNI3fFeTzVkTLcX3nCOHE5hzw5GsOVnuTIOXk6/N4YoDZkHeSVjprBKT0xEv2QTv5ET/Ihjp4SyX++53qkHKR34kT5KbSqB3Hw4PorVWI4+RHGQb6UH9mp3yhXDeqec0vxkZffSI92ItAFT7AkP37L5RQ8IVnnl2RBdvKNT8Ok/RHWheqIo5nAtKHrcC7huU4vXryY5KDOIo3hTPFnbcfGmJ0HNks2BJuJPceW5+NHyeZGZOtnQWMgR7SvwJik32Le2DHsKraMvKPtjOgJxBzY2RzypqyMNUI6yWXJ4TzixTEONG7xP4YjM3rENsfwEhrPkE9gy+M4jf2XnedgHKfu+Byf0E4a6EjxNOYThkyCMYff+R850j6RPdex2oTC0Rff4/iusFq7ERojOSgn55EOchLGeMUYDZRf8kf9oG9kFZrrcJAm6SGz0qScjHugOotl11iZl1ttMh+fY1/ioH0Qh6NvDkI+nEP/Ix3Gc7UvZCYc+B7bsfpOl34lb9QD6Uc96HzpIU9PssT2UoM5hNIV6DnvJ5IdOSIKp50K9WP0hCwc0gtlyvvTUBmANIgb65n6Ql+ER6TLKBvQLzXvjrLRZjmnD/RKurQV+oLqW20qn6+B+iVlpU1QVvkqsb+A7EKsV/XN3G4rT8oQ4TvhJT1R9ojKM1RPHHnbkm0foj+zOK7iT1N5o4FVPa4+6+pj04DSdhKtkLGS2jSktKrKfWJs72qMyBUr4lw95r6RxgBOtdWKVSNWkbmarRVG8uXJvKw6DYG82e7cGKs2ZB3KxVb0xvC2IZthRY4VcG0TajpUWuVqjGb6zuoj21O0ckeZ2fansvN7XM0nH2RAhxF0xkow6ZBHY4jS1YCoJ8qqe6cpv35HN3l407nTSrfCSY8Huig9yoNckptw6pTza3AOR6wH0kV/nE9+XH0orRzSNljpJX3aSl5+9MSqeu38HO7JIk2uqEi31AltMW93eR0BcrOqTFzaLLJxryLlQ0bkIz5x2DpGXoJysnJNeN6ejDGrS243uXLZTPQ22TOuFrJ7qpnIXXElhPO4bxb7hR0cClePsDvR9pInthc7xBjAFcPaVSbGFO7xxU5j+3IYW7rOjzSTxTS+kCc7nJCHNLkKlI+j2PJoowG5saukgS6Ri6upjIGC89APeXWNSUCdMI4ju64kY/OxzRqngStPxKNuAJkZ8/I6ysdsdEda/IdYbsqicsc5CjIzpmhcjOEan5kLqZykQznQy5B2wVipMgP5kzZ58ZlxUPVMHoxX6JcyoBPmTrSbCPM70gRkoMyEcdUVuRoHJ/2mOqW85KH6YXdF1CXlYdeFZCRvdrhpfM770pA5CHAeOx9iGyEP+p3SYLzmQYPonDh8R2fE7dMvtzvoqjztiXNoM4RJD/SXUp2i/zjnYi5IeBfoHNmQkbj8J0/ZlJIeqV/NlxROO6ROOY+6UV3m8HvjsG6aJ0UZSJ84UQbI2z3zSdJANvoM8J1w6oa4qlvSpH1wHrqkrmowv87tSA6+B/LQ3rClpIneoy5IQ30A+cgTeZBFNpu5H9/JE0hT9Uc/oV6Jx5P7Y1lox6SpPNEb/V22WG1jHj1pnlkj6om2jn1bW1vr7T9mcYzOWV8UGDgcZhx5Y4wxZjfBGMik7WL76iljjFkkWpzBmcPpi+BYstBCOA7rdiPZWAiSIy1wNnFQcV5ZTNjNoCcWUKij3PlmERE/CsefBWGzPEZ1z/qiYJWJSQqrYMYYY8xuQmMgO8vsqBtjtgKcPK4K54466Gr/sp6ErudT5I464JRyZbr0224DPeGwl66Sc/Wdq/K+gr58Vu7KOpMUVtPYOsI2JWOMMWY3wRjItsoh25yNMWYWrrnmmuSosyiIYxfhaiy3HvDbMpy966+/PvkDXPXP7SBX/XFSueq+2x1R6YmLm7nPtOw6NJ+zUs667hNjNS+/N8wYY4xZZbSlkcVqj4HGmK2EreTYG+wOV9jl0PGdq9ZDnguwVSAbDjl+AbLoKjqOKQsMOPF2QDfrKdah9TQuVspZ5+EYrO55258xxpjdBvcY1ralGmPMosGp44GCeqAZ9ocjPlRumSCbHuCIw45s+S4AYz2NnZV9wJwxxhhjjDHGGLNTWckHzBljjDHGGGOMMTsZO+vGGGOMMcYYY8zIsLNujDHGGGOMMcaMDDvrxhhjjDHGGGPMyLCzbowxxuwQfvjDH6ZXI9Xo+s0YY4wxOws/Dd4YY4wZObwP99VXX02v1zl37tzk/vvvb3/ZDM76k08+OXniiSeqcYbwwgsvTN5+++322zq80ufYsWOTN998c/LWW2+1oZvhdT9XX311ikv+er9x5JVXXpm88cYb7bdunnnmmd53xqMbyn3kyJE2pBte8/riiy+mhQ/eIYyc+/btS9/JqySzMcYYswzsrBtjjDEjhncZf/TRR5MHH3wwOZRdzjoQ/9FHH5089NBDk0OHDrWh0/PjH/94ctdddyVH+OjRo5Pjx4+3v0ySPPzG/wMHDkzuu+++9G5l5Hvvvfcmr7/+ejoP5/f06dNXvPud8+69996Ux4kTJ654LzNlePrpp5Oz3lcG5CD+xYsX25A6zz777OSll16anDp1anLw4MEkBwsgjz/+eJJ3bW3NzvoKQHvgyNudMcbsNLwN3hhjjBkxe/bsSQ4kV62HQHyc0eeffz5dRZ4V8pQTzZXnCFekb7/99vSZRQGuarOAcPjw4cnJkyeT44wz/N3vfnfD4Y9wvspDHpwbDzn5OPNdfP/7308HiwTk1QXx2DHA4gCyAXKw2MACCHozqwFtgfo2xpidjp11Y4wxZsXgiiJb4bnCzhXGeZn2ajNOMM42jjgON3Lk9DnHnNu3QPHyyy9vLChwm0AXcuZL+ZKGHHizs6G90y6MMWYVsLNujDHGrCDa5s094suCq+ww7ZVObWPuul+dsnH/PIsCOOB87roSLycdpz6/0g/57oFpQJatpm+XwbSgg0Us5MzLosv18MMPz7WjZCtZdFmNMauPnXVjjDFmZOBI4XRwLzX3bnN/97TberV1fplXGclf2+WnkQPnvs8B5r54FiRIn63s0JUHjj8OO/eoszU/d+j4nR0BfbDl/oEHHtioGz7zPIEc7o0nnN+vueaa9DkvE84yDwTkN+r4qquuSvfVy4kmPlv3b7311nRbA9+JSzwO8gDKpPCbbrop6SZCeuxuQObnnntuI78hiwycSzlrMgKfSRs5KQ8yED93TqlX0iA94qEbPgOLLbR5wjjiIhPp851wzistthBGntpBobpBf4I46EF53HHHHSleLEsJ6hxdc07cJcLDDSl3ng9IXvRNHMpN/Aj6lzzIcv3111+RjjFml8MD5owxxhgzDj755JPLe/fuvXz8+PE25PLlCxcu8DDYdJw7d64N7efQoUPpnPPnz7ch03H//fen89fW1tqQz9Fvp06dakPKNI50itc47m3IOpItLw+yEreUZ6RxrJNegHNIi7BLly6lsBLISjwdyPDhhx+2vw4D2c6cOdN+W8/7lltuab+tc/To0XQI5NyzZ88VOuD76dOn22+XL588eTLJpXM578iRIykMPfKZ/AgnT9KkTAcPHkxhkoXwqL9jx45dPnz4cPvtctIRuurTMeQy0i6jjIBcUfekS5y8vMSJ+kZ22pE4e/ZsOi/XJ1C2vvoF1XHerjgvL0usl750gbi5bCorbUmUZKX+qAeBHkgr1sH+/ftTWrQDY4wBX1k3xhhjRoSuoMZXkXFPNQ9emxY9DXuZ24J1Zb12FVdXQOPBleIuuArbODob96s3zlb6TB75VeUIT5ZvHMINmbjSyRVNXaEeAjsc4hVj8taVfeB30o1Pz0c28qRcyA5ceeWKbrxXHvkahzBdXeUqMOfxAD/gOw/HU1lJn/N5jZ6eD8BvPEGf8Fjn77zzzib9kwfPNOgDvZRkBMkIXM2mfKQL1A1tL+aJzvge65a0Gqe2/ba+uwFdEjdvA+RB2ZTHtOiKfCwLOuOhiOQ15Ip2lFVQ1hx0j944BK89jCDPY489tun8p556Kv3n1YLGGAN21o0xxpiRgDODE4djnjslJaegj2uvvTb9f//999P/ZSCHruToAA4oT2PXcenSpU0OVQnuO5djI3B8oG+7PQ4hT6vH2cWhRD4WDPQKuD5w8IgfnTucSME75Kk7tj/Hg/qLCy6vvfZayj/GIU3icEhvIq9/6VMLMqLkzOJIs0jAdmyly2JQrU4EZcllVPuMMp45c2bj+QSgregR8iItZIjbweOiBsipzR1WZNFCwSxQ/lJ5h7abaaCNoBsWnnT7CmGSn3aGPLzmMOqWRRX0Sl0PaYvGmF1Ae4XdGGOMMUuG7dUMzXGLsWgm+sXtvV1oWzXba2ehcRzS+aXt0vqtbxs8W4yJF7dhQ1d5CKtt0W4c7XQe6SKDDuXDwfbmIbAVWdv0OdhO3gdbtRuHOMVvnKortiyTRuMct9/qNI7jFTopgS7IC31FauHaBh7rBZ0hK+GNw5y2Yw/Z9j1URiC9EydOpLZG3pxLnhFtoedonNekyxKqS9UjZc3LWaO0DV5thnaSw20nkqnvlgjKk5cJODfKhy60pZ2DNoYMQvKgD2OM6cJX1o0xxpiRwIOsIL+qOiu6Opdffd0uyF9luvvuu9P/ITROVXUnAVfVG8coXZHlKqwOvms7emkbMVdz8weecaWVq8JHjx5N37na2XdFU1fm+U96bGfmwWg6j/95PiWIN+1DA2eFK+uN45v0RL7casFOAtVNjaFlIQ63ExCf2wyon9IVfvSMHNQvZeeBcFxpz9FOBeQE6nzItv0a2o5f0vdW9A3Kjh5OnTqV2hjtigfM6RYN9AQffPBB+m+MMTXsrBtjjDEjAacKhjhIQ/j444/T/9tuuy393254ajgLDzhnOHDTglMTt0zzHYcHx5w08wNnFHCO4v3SgE5r98KTHk4b6fctlJAuCwk4YxxyxjiA30iH7eI5hGuLOPGQp+RAEraoNgCkRfnYao2zzL3tOOpyhmsgI/df57oEZFQ4jijbvLXoUQK9chDv3LlzyZHFqaV+823zLLoQD52SP/Ij86xo4Yf8a3qlHjn6oA77UB60eRZ20At5s7DD+ZKHtlzSLfoYko8xZvWxs26MMcaMBBxOHBgm6yUnblrkCMg52E5wRHFYcRJxzGp0Ocfcwx2vfJIeV7RrThUOHk4djk508gX3iddAR+TV57BFBxdZcNjh3XffTf/vu+++9J+FirwOOVd1QV1DvI8ckD3GWwTx6jULQjjLtLO+NoaMyMPrxXIZcaLRlZz20pX0CPHiAgaOrNpFSQ4tvLBr4ZFHHkmfpyHKiy5pG5DnpT4SnzvQRe5cyzGP+dH2tGuBNqVdH8QhnDDk4TvPP4gQpuceGGOMnXVjjDFmJDCJl9OAg6QnejPB12ecYDkMXJnjvdclxxRwJJj041TOgvLJHRSoXfkjLo4qV1tx9riyWHI85eSU0gbKhHMt2XFi2N4uZ7iGnGAeGJanzSIIzl90rIAruDhxPFW9D3QeHT4cVnQsuXRVmDx4wBjOGFe09d5x7Z7AgUMvpMWWdD1kjM/79u1LcSK5vmv6F/F38o1tBHmRu69d6OnrtL0oI1veVQ4tpqBDLTKxOIDuOeKuA7azxzrRwkhJDvSIfijHNLsy5OTylHzKTVsEHmTIbyyERN1oYYSnwvehdsxT8ikHOqVMQL8kP6UdF3WAsnK+Fg30QD7aE+0EvSIruo1b/smD9/TX+rgxZsVp7103xhhjzEjQu7V1NM5MekhV42ykB1nxHmc4duxY+p34JRpHavADwiI8nIsHpSn/xsFID1LjYVzkncvH742TvPGfB+TF91lHSudzTjyQm3CVi3P00LHGSay+h5pwfle6jYO08aA1dIUeSR89ok/C0CfxzlYedpZDushHGUkbufgcQU/kJTk40CfhER6ih85ivMaJb39drwfkJZw8KR8PL1O+Cuc74eg8hktPjZOYwmgLxEUW0h3ykDke8hZ1iu54kFwEHep34vIANfTLd9UhZeE7uqaMyEbZ87QixCPtaUDH0im6iA8qpCzoBRmpe2SknmoPM8yhXJRfZVXf4jNpqh7UL0mbctI++F39VvBASeRRenzO26H6St7GjDG7g6v40xgBY4wxxowIrtxxRZ2rcRzaPqurkYKrno3j1X77HK70cXWbe5Qb56UN3b1w1RPdcXWVq5/oB/jeOHXp8zRwPumofkrkdViDOMSlnqjjrUL5kMe0bYIr5uwWQFfoLAd9ED4kXe0SaRzYK9pzhF0QXN2fpX66kB5K/WYIyB/rlLKXZFT9Q1de0kctTq2PG2NWHzvrxhhjzAqCo8MT2I92PPTLmLGi7fQsNhljzG7F96wbY4wxK4au1NlRNzsJ7nnn4Io09/ofax8yZ4wxuxVfWTfGGGNWCLbk4qwfOXKkuF3ZmDHCLQXXX3/9xgPa9ocn7RtjzG7FzroxxhizInBFksP3qJudCE9G5+nqPFmfXSFebDLG7HbsrBtjjDHGGGOMMSNjy5x13heZv2PSGGOM2W188YtfnPzsZz9rvxljjDFmVdjq696+sm6MMcYYY4wxxowMPw3eGGOMMcYYY4wZGXbWjTHGGGOMMcaYkWFn3RhjjDHGGGOMGRl21o0xxhhjjDHGmJFhZ90YY4wxxhhjjBkZdtaNMcYYY4wxxpiRYWfdGGOMMcYYY4wZGXbWjTHGGGOMMcaYkWFn3RhjjDHGGGOMGRl21o0xxhhjjDHGmJFhZ90YY4wxxhhjjBkZdtaNMcYYY4wxxpiRYWfdGGOMMcYYY4wZGXbWjTHGGGOMMcaYUTGZ/P+Cm5t568auCQAAAABJRU5ErkJggg==\"\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eTo measure change in provider stigma we administered a pre/post Acceptance and Action Questionnaire \u0026ndash; Stigma\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The AAQ-S has been shown to be a valid and reliable measure of enacted stigma, with good internal consistency (Cronbach\u0026apos;s alpha\u0026thinsp;=\u0026thinsp;0.84).\u003csup\u003e16\u003c/sup\u003e The pre-survey collected demographic information alongside the AAQ-S questions and was administered as a virtual survey just prior to the IDEAS training. The post-AAQ-S questions were combined with AIM and FIM questions and administered via a virtual survey immediately following the IDEAS training. Post-surveys also included an open-ended item asking providers to share how they were impacted by IDEAS. Surveys prompted participants to generate a code that allowed us to match pre/post surveys while maintaining participant anonymity.\u003c/p\u003e\n \u003cp\u003eA sample size of 20 matched pre-post AAQ-S surveys achieved 90% power to detect a mean difference in AAQ-S scores between 7\u0026ndash;10 points assuming a standard deviation of the differences in AAQ-S scores in the range of 7\u0026ndash;9 points, alpha\u0026thinsp;=\u0026thinsp;0.05, using a two-sided paired t-test. Previous studies yielded approximately 20\u0026ndash;30% unmatched surveys, so the sample size was inflated to 26 matched surveys to account for dropout. Power analysis was performed using PASS 2019.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eTGD Veteran Data Collection\u003c/h2\u003e\n \u003cp\u003eTGD Veteran patients with mental health or primary care appointments were identified using ICD-10 codes for gender identity disorder as well as through patient chart reviews. TGD Veterans were sent a letter describing the study and providing the opportunity to opt out via a phone call to the study team and then received a follow-up call (unless they opted out) from the research assistant who shared information about study participation, answered questions, and conducted the informed consent process. Veterans who consented to participate engaged in a survey with the research assistant immediately following their pre-intervention mental health or primary care appointment. Pre-surveys were completed with TGD Veterans prior to their provider\u0026rsquo;s opportunity to attend IDEAS, and post-surveys were completed after their provider\u0026rsquo;s opportunity to attend IDEAS. However, we did not exclude Veterans whose providers did not attend IDEAS. All TGD Veterans with primary care or mental health appointments in the recruitment window were included, and inclusion criteria were confirmed during the initial conversation with the research assistant.\u003c/p\u003e\n \u003cp\u003eThe TGD Veteran patient survey consisted of items from the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Item Set (CAHPS-CC; quantitative). The CAHPS-CC is an open access assessment available through the Agency for Health Care Research and Quality (AHRQ) that explores several domains of \u0026ldquo;cultural competence\u0026rdquo; such as positive and negative provider communication behaviors, shared decision making, equitable treatment, and trust. Questions are answered using Likert-type rating scales. Patients were asked to complete only 1 pre and 1 post survey per provider. Surveys were administered face-to-face or by phone call, and the interviewer wrote memos to capture comments and/or explanations related to responses offered by Veterans as they completed surveys.\u003c/p\u003e\n \u003cp\u003eWe aimed to recruit 25% of TGD patients receiving primary care and/or mental health VA services within the study site location (one Midwestern US state) during the recruitment period, which was defined as patients with an appointment within 6 months prior to and following IDEAS implementation with providers. We deemed this percentage to be a feasible goal given the study duration and existing number of TGD patients in the healthcare system from which we were recruiting.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e According to the local VA LGBTQ\u0026thinsp;+\u0026thinsp;coordinator, approximately 75 gender diverse Veterans were seeing primary care or mental health providers once or more within 6\u0026ndash;9 months within our study setting and timeline. Thus, our feasibility benchmark was set at 18 Veterans (approximately 25% of 75). Our goal regarding feasibility was that 18 TGD Veterans would complete the informed consent process and both baseline and follow-up surveys, including the CAHPS-CC survey described above as well as a survey created by the authors, designed to detect more nuanced experiences specifically pertinent to the TGD population. This benchmark was created as a precedent for a future national study powered to detect meaningful pre/post changes in TGD Veteran experiences with their providers. Based on the number of TGD Veterans receiving VA care nationally, a 25% percent recruitment rate would adequately facilitate this goal.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eAnalyses\u003c/h3\u003e\n\u003cp\u003eAAQ-S surveys provide a composite score, with lower scores indicating reduced enacted stigma. An unadjusted two sample paired t-test was used to assess the change in AAQ-S scores in matched pre-post surveys. Adjusted effects using Generalized Linear Mixed Models (GLMM) allowed for adjustment for relevant covariates and incorporation of random effects to account for possible sources of heterogeneity in AAQ-S scores. All analyses were performed in SAS 9.4 and all tests were performed using a significance level 0.05. We performed basic content analysis\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e of the qualitative feedback collected from providers via the open-ended survey question regarding their experience of IDEAS.\u003c/p\u003e\n\u003cp\u003eThis study was not powered to detect meaningful change in patient CAHPS-CC pre/post outcomes but rather, to explore the feasibility of this nested data collection method to inform a future, larger trial powered to assess the impact of IDEAS (and resulting provider stigma reduction) on TGD Veterans. We tracked how many total matched pre/post surveys we collected from TGD Veteran patients. In addition, trends in pre/post CAHPS-CC surveys are reported below alongside qualitative data from memos, which were drafted while patients completed surveys. In addition to using the CAHPS-CC, we collected TGD Veteran data using the Occupational Therapy Gender Affirming Care (OGA; blinded citation) survey, which is an author-created survey that asks questions about aspects of healthcare that TGD patients deemed to be important. This survey\u0026rsquo;s psychometric characteristics has yet to be studied. It was therefore solely used as an adjunct to the existing, validated CAHPS-CC items to collect information more closely tied to the TGD population and as a means of further exploration of the utility of this new instrument.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eProvider Participant Characteristics\u003c/h2\u003e\n \u003cp\u003eProvider participant demographic characteristics and comparison of baseline AAQ-S scores are listed in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Thirty providers completed a pre-test only, and 45 providers completed both a pre and matched posttest. We found no significant demographic differences between providers who completed matched pre/posttests and those who only completed a pretest (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). We found no significant differences between primary care versus mental health providers (data not shown). However, the group who completed both pre and posttests scored higher on the pretest (indicating higher stigmatizing thoughts) than those who only completed a pretest.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eProvider participant characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eBaseline Characteristic\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMatched\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3684\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (24.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (36.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45\u0026ndash;54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (21.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55\u0026ndash;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65\u0026ndash;74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHispanic/Latino/Spanish Origin\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2176\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (96.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (98.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhite\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4480\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (22.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (25.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (77.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (74.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlack/African American\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.3099\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (91.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (88.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (8.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (12.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmerican Idian/Alaskan Native\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4111\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (97.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (98.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAsian\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2239\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (96.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (92.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNative Hawaiian or Pacific Islander\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.2176\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (96.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (98.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAre you a current or former military service member\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4191\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot a service Member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (96.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (91.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurrent Member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFormer Member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelect the option that best describes your role\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.4927\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMental health provider\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32 (72.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (67.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary Healthcare Provider\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (36.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (28.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVeteran Panelist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is the highest degree or level of school you have completed\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.6584\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAssociate Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelors Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMasters Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (48.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37 (49.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoctorate/Professional Degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (43.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (45.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.1931\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCisgender female (my gender matches my sex at birth)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (86.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31 (68.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e57 (76.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCisgender male (my gender matches my sex at birth)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransgender male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003eChi-Square\u0026nbsp;p-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eProvider Stigma\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates change in provider stigma. Among the 45 providers with matched AAQ-S pre and post scores we found an average change score of -4.5 (11.61) among mental health providers and \u0026minus;\u0026thinsp;6.7 (13.85) among primary care providers, with a total average change score of -5.0 (12.04) indicating a decrease in provider stigma in both groups after engaging in IDEAS (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Change scores within this population ranged from \u0026minus;\u0026thinsp;54 to 10. The change scores among mental health versus primary care providers were not significantly different from one another (p\u0026thinsp;=\u0026thinsp;0.87).\u003c/p\u003e\n \u003cp\u003eTable 3. Pre/post Change in AAQ-S\u003c/p\u003e\n \u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eFeasibility, Acceptability, and Qualitative Feedback\u003c/h2\u003e\n \u003cp\u003eRegarding IDEAS acceptability, all items on the AIM were rated above 4 (agree), with a total acceptability average score of 4.33. Average scores were as follows, with the minimum and maximum values for each item being 3 (neither agree nor disagree) and 5 (strongly agree) respectively: IDEAS meets my approval (4.39); IDEAS is appealing to me (4.34); I like IDEAS (4.32); and I welcome IDEAS (4.24). IDEAS was also feasible according to provider ratings, with a total feasibility score of 4.26 and item scores as follows: IDEAS seems implementable as an ongoing training (4.24); IDEAS seems possible to implement in the future (4.29); IDEAS seems doable as an ongoing training (4.27); and IDEAS seems easy to use (4.22). Feasibility items also had a minimum and maximum value of 3 and 5, respectively.\u003c/p\u003e\n \u003cp\u003eOf the 56 posttests completed, 24 providers offered qualitative feedback about IDEAS. All feedback was positive and spoke to the value of the film and guest speakers (e.g., \u0026ldquo;It really put a face to the issue and made me think about what I can do to ensure that I am treating trans Veterans with the care and respect they deserve\u0026rdquo;) as well as the impact IDEAS had on providers\u0026rsquo; motivation and self-efficacy to initiate change. For instance, one provider noted: \u0026ldquo;The first vignette in the video posed a challenge to providers to help shift the culture of the VA\u0026hellip;this is a lofty but important goal that I would love to participate in.\u0026rdquo; Another expressed that: \u0026ldquo;Some of it was really eye opening and makes me feel more sensitive to the good and bad experiences that might emerge. I feel more empowered that my interactions with transgender folks can make a big difference.\u0026rdquo;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eImpact of IDEAS on Gender Diverse Veterans\u003c/h2\u003e\n \u003cp\u003eThirty-seven gender diverse Veterans completed surveys prior to IDEAS implementation, and 18 completed surveys following IDEAS implementation. All the Veterans who completed a posttest had a matched pretest, thus we were able to meet our benchmark for feasibility success regarding TGD Veteran participant recruitment. Post-survey completion was limited by project staffing changes which posed challenges to follow-up data collection. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e describes TGD Veteran participant characteristics as well as average pre/post scores on both surveys (CAHPS-CC and Occupational Therapy Gender Affirming Care Survey), average change on each item, and total change on each survey.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTGD Veteran Characteristics and Survey Responses\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDemographic Characteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAge\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u0026ndash;34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35\u0026ndash;64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e65+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEthnicity\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHispanic, Latino, or Spanish origin?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRace*\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBlack or African American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAmerican Indian or Alaska Native\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMilitary Status\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCurrent service member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFormer service member\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEducation\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLess than high school diploma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHigh school degree or equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSome college, no degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAssociate degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBachelor\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaster\u0026rsquo;s degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDoctorate or professional degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eGender\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransgender female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTransgender male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNon-binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e*\u003cem\u003enote.\u003c/em\u003e Numbers for race do not equal 37 or 100% due to identification with multiple races among participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eCAHPS-CC Survey\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre (max/min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost (max/min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eChange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eCommunication \u0026ndash; Positive Behaviors (1 Never, 2 Sometimes, 3 Usually, 4 Always)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did this doctor explain things in a way that was easy to understand?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.65(4/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.76(4/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did this doctor listen carefully to you?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.68(4/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.88(4/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did this doctor spend enough time with you?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.49(4/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.76(4/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did this doctor show respect for what you had to say?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.92(4/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did this doctor give you easy to understand instructions about taking care of these health problems or concerns?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.68(4/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.82(4/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eCommunication \u0026ndash; Negative Behaviors (1 Always, 2 Usually, 3 Sometimes 4 Never)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did this doctor interrupt you when you were talking?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.81(4/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.88(4/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did this doctor talk too fast when talking with you?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.73(4/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.82(4/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eCommunication \u0026ndash; Negative Behaviors (1 Yes Definitely, 2 Yes Somewhat, 3 No)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, did this doctor ever use a condescending, sarcastic, or rude tone or manner with you?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.97(3/2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.0(3/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eShared Decision Making (0 No, 1 Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, did this doctor talk with you about the pros and cons of each choice for your treatment or health care?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.88(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, when there was more than one choice for your treatment or health care, did this doctor ask which choice you thought was best for you?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.73(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eEquitable Treatment (1 Always, 2 Usually, 3 Sometimes, 4 Never)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often have you been treated unfairly at this doctor\u0026apos;s office because of your race or ethnicity?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.95(4/3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often have you been treated unfairly at this doctor\u0026apos;s office because of the type of health insurance you have or because you don\u0026apos;t have health insurance?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eTrust (0 No, 1 Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDo you feel you can tell this doctor anything, even things that you might not tell anyone else?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.78(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDo you trust this doctor with your medical care?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0(1/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDo you feel this doctor always tells you the truth about your health, even if there is bad news?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0(1/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eDo you feel this doctor cares as much as you do about your health?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.84(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.94(1/0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eTrust (1 Never, 2 Sometimes, 3 Usually, 4 Always)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eIn the last 12 months, how often did you feel this doctor really cared about you as a person?\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.59(4/1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.0(4/4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupational Therapy Gender Affirming Care Survey\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHigher scores indicated more desirable services. All items scored as follows unless otherwise indicated by * (1 Strongly disagree, 2 Somewhat disagree, 3 Neither disagree nor agree, 4 Agree, 5 Strongly Agree)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider listens carefully to me.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eWhen there is more than one choice for my treatment or health care, my provider asks which choice I think is best for me.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI feel my provider always tells me the truth about my health, even if there is bad news.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider explains things in a way that is easy to understand.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider shows respect for what I have to say.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI feel my provider spends enough time with me.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e*I feel that I am treated unfairly at my provider\u0026apos;s office because of my race, ethnicity, or gender identity.\u003c/em\u003e (Reverse scored: 1 Strongly agree, 2 Somewhat agree 3 Neither agree nor disagree, 4 Somewhat disagree, 5 Strongly disagree)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI trust my provider with my medical care.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider believes me when I share my health concerns.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider is knowledgeable about my gender identity and related healthcare treatment.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e*I must advocate for myself in order for my provider to treat me with appropriate care related to my gender identity.\u003c/em\u003e (Reverse scored: 1 Strongly agree, 2 Somewhat agree 3 Neither agree nor disagree, 4 Somewhat disagree, 5 Strongly disagree)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider acknowledges all of my identities when providing holistic care.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider explains the purpose of medical procedures and professionals who are involved in my care.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAll the staff at my provider\u0026apos;s office affirm my gender.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider listens to my feedback and makes appropriate changes.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider fully addresses and resolves my medical concerns\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e*My provider asks me to educate them about my gender identity, and/or I need to educate my provider to ensure that I am provided proper care.\u003c/em\u003e (Reverse scored: 1 Strongly agree, 2 Somewhat agree 3 Neither agree nor disagree, 4 Somewhat disagree, 5 Strongly disagree)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e(referring to prior question) Is this a positive thing or is it a frustrating thing?\u003c/em\u003e (0 Not applicable, 1 Frustrating, 2 Positive)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider acknowledges and understands my gender identity.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider acknowledges the potential dysphoria related to certain tests and procedures and takes steps to alleviate the potential for dysphoric harm.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eMy provider is sensitive to potential dysphoria and limits requests to ask me to take off my clothes.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Score/Average Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e87.09(4.15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e94.26(4.49)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.17(0.34)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe observed an average pre/post change score of -5 among healthcare providers, indicating the possibility that IDEAS may decrease enacted provider stigma. The AAQ-S measures psychological flexibility and inflexibility regarding stigmatizing thoughts, with decreasing enacted stigma being conceptualized as an increase in the former and a decrease in the latter; an improved score suggests a provider may still experience stigmatizing thoughts but has greater flexibility regarding whether and how they respond to such thoughts.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e A change score of -5 is smaller than that observed in prior studies of non-VA providers,\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e suggesting the need for future exploration of IDEAS among providers in different settings and different clinical backgrounds that also examines qualitative experiences of providers surrounding IDEAS.\u003c/p\u003e \u003cp\u003eAlthough this study was not powered to detect meaningful pre/post change on TGD Veteran surveys, it is worth noting the trend in pre/post scores on both surveys. All but one of the CAHPS-CC items improved from baseline to follow-up, suggesting a positive trend in which Veterans perceived providers to be demonstrating increased cultural competence after IDEAS training. No item scores decreased from baseline to follow-up, and one item remained the same: \u003cem\u003eIn the last 12 months, how often have you been treated unfairly at this doctor\u0026rsquo;s office because of the type of health insurance you have or because you don\u0026rsquo;t have health insurance?\u003c/em\u003e The average response to this item at baseline and follow-up was 4 (Never), which makes sense given that private health insurance status does not influence access to VA healthcare. On the Occupational Therapy Gender Affirming Care Survey only one item decreased from baseline to follow-up: \u003cem\u003eMy provider explains the purpose of medical procedures and professionals who are involved in my care\u003c/em\u003e. The average baseline score of 4.68 (agree/strongly agree) decreased by 0.18 points to 4.50, still falling in the agree/strongly agree range.\u003c/p\u003e \u003cp\u003eThe occupational therapist research assistant took memos while conducting pre and post surveys. Some observations from these memos illustrate factors that may have impacted scores and could provide directions for future evaluation.\u003c/p\u003e \u003cp\u003eFirst, some Veterans had conditions that they reported contributed to them scoring their providers lower than average. For example, one autistic non-binary young person scored their provider notably lower than average on the pre-CAHPS-CC, reporting that they felt negatively about most healthcare experiences, due to providers not allowing time for cognitive processing. This is reflective of existing literature documenting that gender diverse patients with comorbid conditions face greater health disparities, resulting in lower overall patient satisfaction.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eSecond, it was consistently noted that Veterans over 55 described generally lower standards for gender affirming care. For example, a positive assessment of a provider may be one that does not blatantly deny the existence of gender diversity, even if the provider was not knowledgeable regarding the range of gender diverse identities and associated specific care considerations. Veterans over 55 were more likely to describe having a long relationship with their provider, whom they felt knew them as a person, which they reported contributed to positive perceptions of providers even when the providers were not knowledgeable about their gender and related healthcare needs. By contrast, younger TGD Veterans had higher expectations that providers were knowledgeable and affirming about their identities and care requirements.\u003c/p\u003e \u003cp\u003eThird, several respondents noted that one of the survey questions regarding whether providers spend enough time with the patient is perceived as an issue with the VA system rather than the provider and therefore Veterans were resistant to scoring providers low on this item. Therefore, it is worth noting that there may be more systemic VA issues impacting care that are not captured by baseline or follow-up scores from this study. A study by Kcomt\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e discussed the importance of addressing institutional policies to decrease profound discrimination of transgender and gender diverse patients. Our findings reflect the importance of evaluating the larger institutional factors impacting healthcare quality, which would not be captured by surveys about satisfaction with healthcare providers. Many such measures are in place, further illuminating how patient care depends on a number of personal and contextual factors within a healthcare system that require evaluation and remediation.\u003c/p\u003e \u003cp\u003eSome Veterans noted that front desk staff misgender them over the phone, even when they believe that pronouns are clearly visible within the Veteran\u0026rsquo;s medical record. Veterans also noted that care from residents was markedly less affirming than care from their typical attending providers, indicating the importance of gender affirming care training requirements for trainees as they step into their professional identities and responsibilities as primary care and mental health providers. Current educational curricula focused on TGD populations in medical school is \u0026ldquo;largely composed of one-time attitude and awareness-based interventions\u0026rdquo;, which has been deemed inadequate to target these systemic inequalities.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e A shift towards a more clinical-skills based curricula that is woven throughout medical school may facilitate bridging the gap between systemic barriers and healthcare inequities experienced by the TGD population.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study\u0026rsquo;s findings are limited to VA healthcare facilities within one Midwestern state, and primarily referred to experiences within a large VA hospital in a central, urban location. As such, Veteran survey responses do not adequately reflect TGD VA experiences across the United States. For example, one Veteran mentioned traveling across state lines to receive gender affirming care. This Veteran expressed that their survey responses were specific to the study location (which is where they traveled to for care) but would misrepresent the other VA system in which they had received less gender-affirming care. They specifically discussed their perception that the VA was not as a whole gender affirming, requiring them to seek out specific places within the VA that were equipped to provide them with good care. Given this perception of the VA system in which our study was set, findings (largely positive patient satisfaction pre and post IDEAS) should be interpreted in this context. The contrast in quality of TGD healthcare based on location has been echoed by Gonzales\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e which found TGD adults who seek care in states with stronger TGD protections report less mental distress versus their TGD peers who seek care in states with fewer TGD protections\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIDEAS is a feasible, acceptable, and effective intervention for reducing provider biases that may negatively impact healthcare equity for TGD Veterans. Further research is needed to measure the impact of IDEAS provider trainings on the care of TGD Veteran patients. However, preliminary results are promising regarding the perceptions of providers following IDEAS trainings among TGD Veterans. Existing open-access surveys such as the CAHPS-CC items capture some information regarding healthcare experiences but may benefit from additional items that inquire about priorities identified by TGD patients. Further evaluation of such assessments is warranted.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVA: Veterans Affairs\u003c/p\u003e\n\u003cp\u003eTGD: Transgender and gender diverse\u003c/p\u003e\n\u003cp\u003eAIM: Acceptability of Intervention Measure\u003c/p\u003e\n\u003cp\u003eFIM: Feasibility of Intervention Measure\u003c/p\u003e\n\u003cp\u003eAAQ-S: Acceptance and Action Questionnaire – Stigma\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCAHPS-CC: Consumer Assessment of Healthcare Providers and Systems – Cultural Competence\u003c/p\u003e\n\u003cp\u003eICD: International Classification of Diseases\u003c/p\u003e\n\u003cp\u003eAHRQ: Agency for Healthcare Research and Quality\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003e \u003cb\u003eEthics approval and consent to participate\u003c/b\u003e:\u003c/strong\u003e \u003cp\u003e All participants completed the informed consent process in accordance with the Declaration of Helsinki. This study was approved by Indiana University IRB number 16200 and VA Research and Development as exempt.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003en/a\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis study was funded by the US Department of Veterans Affairs Pilot Grant number I21HX003615-01A1\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.W. made substantial contributions to the conception of this work and wrote the main manuscript text including tables 1, 3, and 4.J.B. and M.U. made substantial contributions to the conception of this work, assisted in qualitative analysis, and helped with manuscript preparation. F.P. made substantial contributions to the design of this study, prepared table 2, and completed the quantitative analyses and analytic reports.D. B. made substantial contributions to the conception and design of this work and made substantial revisions to this manuscript. All authors reviewed and approved this manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgments:\u003c/h2\u003e \u003cp\u003eThis study would not have been possible without the participation of providers and those who so willingly shared their stories\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData are provided within the manuscript - supplementary information is available by emailing the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGates GJ, Herman JL. \u003cem\u003eTransgender military service in the United States.\u003c/em\u003e The Williams Institute at UCLA School of Law; 2014. 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State policies and health disparities between transgender and cisgender adults: Considerations and challenges using population-based survey data. J Health Polit Policy Law. 2022;47(5):555\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1215/03616878-9978117\u003c/span\u003e\u003cspan address=\"10.1215/03616878-9978117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6156715/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6156715/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Transgender and gender diverse (TGD) Veterans face significant health disparities, often exacerbated by provider stigma. The US Department of Veterans Affairs (VA) prioritizes research to improve care for TGD Veterans. This study evaluates the feasibility and acceptability of the IDEAS - a film-based intervention designed to reduce provider stigma and improve clinical encounters for TGD Veterans.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A pre/post quasi-experimental design was used to assess the impact of the IDEAS intervention on provider stigma and TGD Veteran experiences. The study involved primary care and mental health providers from a Midwestern VA Medical Center and TGD Veterans who had appointments within six months before and after the intervention. Providers completed the Acceptability of Intervention Measure (AIM) and Feasibility of Intervention Measure (FIM) post-IDEAS, and the Acceptance and Action Questionnaire – Stigma (AAQ-S) pre and post-intervention. TGD Veterans completed the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Item Set (CAHPS-CC) and an author-created survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The IDEAS intervention was found to be both acceptable and feasible, with average AIM and FIM scores above 4. Provider stigma, as measured by the AAQ-S, decreased significantly post-intervention (p\u0026lt;0.01). TGD Veterans reported improved perceptions of provider cultural competence and affirming care post-intervention, with notable improvements in communication, trust, and respect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The IDEAS intervention shows promise in reducing provider stigma and enhancing the healthcare experiences of TGD Veterans. Further research is needed to explore the long-term impact of such interventions on TGD Veteran health outcomes and to refine assessment tools for capturing nuanced patient experiences.\u003c/p\u003e","manuscriptTitle":"A pre/post quasi-experimental study of provider stigma and Veteran experiences surrounding a narrative “IDEAS” intervention to promote positive clinical encounters","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-10 06:43:49","doi":"10.21203/rs.3.rs-6156715/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-10T13:14:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-07T08:11:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-07T08:11:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-04T19:04:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b4e3a8d3-b9b8-439b-ada2-4fe4415274ea","owner":[],"postedDate":"March 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:03:12+00:00","versionOfRecord":{"articleIdentity":"rs-6156715","link":"https://doi.org/10.1186/s12889-025-24494-2","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-10-01 15:57:48","publishedOnDateReadable":"October 1st, 2025"},"versionCreatedAt":"2025-03-10 06:43:49","video":"","vorDoi":"10.1186/s12889-025-24494-2","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24494-2","workflowStages":[]},"version":"v1","identity":"rs-6156715","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6156715","identity":"rs-6156715","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}