Moderators of Treatment Outcomes for LGBTQ+ Military Veterans in the PRIDE in All Who Served Health Promotion Group

Background Veterans who identify as lesbian, gay, bisexual, transgender, queer, questioning, and related identities (LGBTQ+) have faced discrimination that puts them at increased risk for depression, anxiety, and suicide. Upstream interventions like the PRIDE in All Who Served program can improve internalized prejudice, suicide attempt likelihood, symptoms of depression, and symptoms of anxiety by addressing minority stress, facilitating social connection, and promoting engagement with the healthcare system. Yet, little is known about who benefits most from these types of services. Methods Sixty-six US military veterans (Mean age = 47.06, SD = 13.74) provided outcome surveys before and after a 10-week health promotion group for LGBTQ+ individuals at one of 10 Veterans Health Administration (VA) Medical Centers. Coping self-efficacy and key demographic factors were examined as moderators of treatment outcomes. Results Coping self-efficacy moderated effects across treatment outcomes with those lower in coping self-efficacy beliefs reporting the greatest benefit of the intervention. Reduction in anxiety symptoms was moderated only by problem-solving coping self-efficacy, while suicide attempt likelihood was moderated only by social support. Reduction of internalized prejudice and depression symptoms were moderated by both problem-solving and social support coping self-efficacy, while thought-stopping (a frequent target of traditional cognitive therapies) only moderated internalized prejudice, but not clinical symptom indicators. Most demographic factors (e.g., age, race, gender) did not impact treatment outcomes; however, sexual orientation was significant such that those who identified as bisexual, queer, or something else (e.g., pansexual) had greater reductions in internalized prejudice than their single gender-attracted peers. Conclusion Individual differences like coping self-efficacy and sexual orientation are rarely considered in clinical care settings when shaping policy or implementing tailored programs. Understanding implications for who is most likely to improve could inform program refinement and implementation of affirming interventions for minoritized people. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Acknowledgments/ Funding: This work was supported by a series of investments from the VHA Innovation Ecosystem, including Seed and Spread Awards (Lange & Hilgeman, Co-Leads, 2017-2019) and Diffusion of Excellence Support (Lange & Hilgeman, Co-Leads 2020-2021, and Sperry & Hilgeman, Co-Leads 2021-2023). Dr. Wilson is supported by IK2HX002398. We deeply appreciate the commitment and ongoing partnership with Blaine Fitzgerald, Diffusion Specialist PRIDE in All Who Served Group facilitators at early adopting sites and Operations Partners including the VHA Innovation Network, Diffusion of Excellence, the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ+) Health Program Office, and the Office of Health Equity. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The PRIDE in All Who Served program was funded by the VHA Innovation Ecosystem as an innovation investment program. From October 2017 to September 2019, ten VHA sites participated in data collection efforts for program evaluation and quality improvement purposes. Procedures were reviewed by the Tuscaloosa VA Medical Center Institutional Review Board (Project title: [1316792-1] Serving All Who Served: Improving Access to Health Care for LGBT Veterans IRB Reference #: 00254/19-01) and the VA Central Office program sponsor consistent with federal regulations (e.g., VA Program Guide 1200.21: VHA Operations Activities That May Constitute Research). Informed consent was completed as a verbal discussion in a group setting (during the 1st and 10th sessions of the 10-week group), with written instructions presented on the first page of the paper survey packets. Outcome questionnaires were collected anonymously using a participant-created ID consisting of letters and numbers to connect assessments over time. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Not Applicable The data underlying the results presented in the paper are available from the first author pending acceptable data use agreements.