A Video Intervention for Professionals Working with Transgender and Gender Nonconforming Older Adults

There is consensus that providers who work with transgender and gender nonconforming (TGNC) older adults should use the language preferred by the older adult; however, selfefficacy in this particular context is unexplored. The current study compared the efficacy of three online interventions for aging-focused professionals designed to increase knowledge of TGNC-related terminology, decrease self-reported negative attitudes towards TGNC individuals, and increase self-efficacy for affirmative interactions. Employees and volunteers of area agencies on aging across the United States (N = 155) were randomly assigned to one of three interventions: written educational information, a video demonstration, or both the written educational information and the video demonstration. It was hypothesized that individuals in the video intervention group would show greater improvements in the three domains compared to those in the written educational group. Results for this set of hypotheses showed a decrease in anti-TGNC attitudes and increase in self-efficacy for affirmative interactions in both intervention groups with neither group showing greater impact on these variables. It was also hypothesized that individuals in the combined written and video intervention group would show greater improvements in the three domains compared to those in the written educational group. Again, results showed no difference between interventions; participants in both conditions demonstrated a decrease in anti-TGNC attitudes and an increase in self-efficacy. Future directions include introducing a waitlist control group, replication of these findings, and consideration of a development model for continuing education. VIDEO INTERVENTION FOR PROFESSIONALS 5 A Video Intervention for Professionals Working with Transgender and Gender Nonconforming Older Adults The number of older adults is rapidly increasing in the United States, with approximately 20% of citizens projected to be 65 or older by the year 2030 (Administration on Aging, 2012). Transgender and gender nonconforming (TGNC) older adults tend to be an unconsidered minority among the aging population; however, the number of TGNC older adults is also increasing (Witten, 2003, 2009). Any estimation is unlikely to reflect the actual number of TGNC older adults due to the fear of persecution and abuse that maintains these individuals’ perceived need for anonymity. This risk of discrimination, faced by all TGNC individuals, extends to older TGNC adults seeking aging-focused services. Social services, which include those services offered by area agencies on aging, have thus far focused little on TGNC aging issues (Witten, 2014). This lack of attention is likely due to a number of interrelated concerns, beginning with the conflation of “gay” and TGNC (Lev, 2007). The confusion of these terms has led to a superficial concentration on TGNC and homosexuality as one and the same. The literature reflects a genuine focus on aging lesbians and gay men, while there remains a dearth of information on issues facing TGNC older adults and those who aim to serve them (Fredriksen-Goldsen, Hoy-Ellis, Goldsen, Emlet, & Hooyman, 2014; Porter et al., 2016). Perceptions of “LBGT” (lesbian, gay, bisexual, and transgender) individuals in the United States are rapidly shifting and the gerontology literature reflects these changes. However, the literature uses a narrow definition of LGBT that more often than not is less than inclusive. Regardless of the good intentions and the merit behind this VIDEO INTERVENTION FOR PROFESSIONALS 6 social and psychological shift, TGNC individuals of all ages are often viewed as a last priority or even excluded from larger LGBT social movements and research. The current study assumes that aging-focused providers desire to more confidently provide care to TGNC older adults and are willing to expand their knowledge of this oft-neglected population. Social cognitive theory emphasizes the role of self-efficacy in acquiring a new behavior (Bandura, 1977; Bandura, 1982; Bandura, 1997). Self-efficacy, as defined by Bandura, is the level of confidence one possesses that one can perform a given behavior in a specific domain. This confidence varies across domains, which means that individuals may experience a high level of self-efficacy in one area and low self-efficacy in a different area. For example, providers working with older adults may demonstrate high levels of self-efficacy when speaking with cisgender older adults, but may experience low levels of self-efficacy when interacting with TGNC older adults; however, there is no literature to support this supposition. Bandura’s Theory of Self-Efficacy Social cognitive theory provides an explanation for the ways in which individuals learn and engage in new behaviors (Bandura, 2001). Internal and external factors interact to determine the acquisition of a new behavior. Internal factors include cognitions, emotional states, previous experiences, expectancies, and goals. External factors include the social and physical contexts of the individual while learning. The interaction between the person, the context, and the behaviors determines the manner in which a person learns the new behavior. VIDEO INTERVENTION FOR PROFESSIONALS 7 As previously mentioned, self-efficacy, or the level of confidence one has that one can perform a specific behavior, is domain-specific (Bandura, 1977; Bandura, 1982; Bandura, 1997). Self-efficacy directly impacts one’s ability to persist at said behavior, despite obstacles. These beliefs about one’s ability to perform a specific behavior originate from various experiences. Self-efficacy beliefs may derive from vicarious learning experiences, during which an individual observes another individual successfully perform the given behavior (Bandura, 1977; Bandura, 1982; Bandura, 1997). This experience is most powerful when the individual performing the behavior is similar to the observer. Other experiences that may generate self-efficacy beliefs include performance accomplishments, verbal persuasion, and physiological state changes (Bandura, 1977; Bandura, 1982; Bandura, 1997). The most effective experience for increasing self-efficacy is performance accomplishments, while vicarious experiences follow in power. Information provided by an expert and other forms of persuasive learning are less powerful in shaping selfefficacy (Bandura, 1997). Self-efficacy theory has provided a fruitful framework in the development of diversity-based interventions for professionals. Video-Based Interventions A professional education program aimed at increasing knowledge, improving attitudes, and enhancing self-efficacy in interactions with sexual minorities may prove relevant for the development of a similar program for providers working with TGNC older adults. A video-based diversity training for physical and occupational therapists was designed and implemented with the goal of utilizing a motivational interviewing framework to conceptualize participants’ perceptions of their own knowledge, attitudes, VIDEO INTERVENTION FOR PROFESSIONALS 8 and self-efficacy when working with LGBT individuals with spinal cord injuries (Burch, 2008). The study also measured the effect of the training program on participants’ perceptions of their ability to change. The transtheoretical model was used to identify health care providers’ readiness to serve LGBT individuals with spinal cord injuries (SCI) using three variables: knowledge, attitudes, and self-efficacy. Approximately four hundred health care professionals who provided services to those with SCI were surveyed. The sample included nurses, physical therapists, occupational therapists, and physicians (Burch, 2008). Following a viewing of the video entitled Issues that Health Care Providers Confront When Providing Services to the GLBT Population, the participants participated in a discussion period during which peers were able to further educate each other on topics related to sexual orientation. The video created for this study used the concept of vicarious experience in an effort to increase self-efficacy in the participants (Burch, 2008). The script for the videoed lecture, which was written by the principal investigator and filmed in front of a live audience, was written based on the research questions in the study and shaped by concepts within motivational interviewing. The preand post-intervention questionnaire created for this study included items intended to measure participants’ knowledge, attitudes, and selfefficacy when providing services to individuals with SCI who may be LGBT This study demonstrated how most providers had not considered issues of diversity in sexual orientation among those with spinal cord injuries and again confirms that negative attitudes towards LGBT people exist among health care providers (Burch, 2008). In addition, the term “heterosexism” was used to describe health care providers’ assumptions that all clients are or should be heterosexual. These assumptions might VIDEO INTERVENTION FOR PROFESSIONALS 9 contribute to less than supportive provider/client interactions, such as when health education material is provided that does not include language or visuals inclusive of LGBT individuals. Heterosexism may also include using language that ignores LGBT relationships (Burch, 2008). Potential areas of growth in this study include measurement and specificity in language. The post-intervention questionnaire consisted of 6 items, the first three of which asked participants to rank their responses on whether the video intervention changed their knowledge, attitudes, and self-efficacy toward providing services to LGBT patients (1 question to address each; Burch, 2008). The final three questions asked the participants to evaluate how the video changed the way they think about the written, verbal, and audiovisual language they use and whether this language is inclusive. Based on Bandu