Background: Transgender and gender diverse (TGD) people in remote areas face structural barriers to accessing gender-affirming, interdisciplinary healthcare. These include limited specialised care, a shortage of TGD-informed healthcare professionals, long travel distances to urban care centres, and insufficient local crisis support. The i²TransHealth intervention addressed these gaps by offering video consultations, chat-based support, and a network of locally trained physicians (general practitioners, psychiatrists). This qualitative process evaluation identified enabling and hindering aspects to inform recommendations for improving and scaling i²TransHealth, and to support the implementation of e-health in other TGD-informed care contexts.
Methods: i²TransHealth was evaluated as an e-health intervention in a randomised controlled trial involving 174 TGD adult participants (aged 18 and above) from northern Germany. As part of the intervention group, service users received video consultations and chat-based support provided by study therapists, along with outpatient care from general practitioners and psychiatrists as needed. To capture the experiences of those involved in delivering and receiving the intervention, four online focus groups were conducted with service users (n = 4), study therapists (n = 5), general practitioners (n = 6), and psychiatrists (n = 7). Data were collected using semi-structured interview guides and analysed according to Kuckartz's thematic text analysis.
Results: The process evaluation identified enabling and hindering aspects influencing the implementation of i²TransHealth. Focus group participants reported improved access to TGD-informed healthcare through i²TransHealth, though this was challenged by factors such as time constraints, administrative burdens, and limited referral options for specialised care. They highlighted the flexibility and support of study therapists, as well as reduced distress and increased wellbeing of service users. While video consultations facilitated access, they were considered challenging for assessing non-verbal cues and treating highly distressed individuals. The e-health platform enabled easily accessible communication, yet usability issues, inconsistent engagement, and high workload for study therapists were noted.
Conclusions: E-health interventions like i²TransHealth can enhance access to TGD-informed healthcare in remote areas, but require integration with in-person services for complex cases involving highly distressed individuals. Expanding training, strengthening networks, and refining digital tools are crucial for sustainability.
Trial registration: The trial was registered in ClinicalTrials.gov 28/02/2020 (NCT04290286).
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