Improving the Organizational Social Context to Address Structural Racism and Discrimination: A Randomized Controlled Trial to Reduce Racial Disparities in Viral Suppression and Retention in HIV Care

改善组织社会环境以解决结构性种族主义和歧视：一项旨在减少艾滋病毒护理中病毒抑制和保留方面种族差异的随机对照试验

• 批准号: 10474854
• 负责人: JOHN BARTON JEMMOTT
• 金额: $ 81.75万
• 依托单位: UNIVERSITY OF PENNSYLVANIA
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-16 至 2027-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10474854
• 关键词: Address; Affect; African American; African American population; Age; Attitude; Behavior; Biometry; Black Populations; Black race; Caring; Clinic; Clinical; Collaborations; Data; Discrimination; Education; Epidemic; Ethnic group; Evidence based intervention; Evidence based practice; Geographic Information Systems; Goals; HIV; HIV diagnosis; Healthcare Systems; Hispanic Populations; Individual; Insurance; Literature; Measures; Mediating; Mental Health; Modeling; Neighborhoods; Organizational Culture; Outcome; Outcome Study; Outcomes and Health Services Research; Outpatients; Patient Care; Patient-Focused Outcomes; Patients; Pattern; Perception; Personal Satisfaction; Persons; Phase; Philadelphia; Population; Poverty; Preparation; Psyche structure; Psychometrics; Public Health; Publishing; Quality of Care; Randomized; Randomized Controlled Trials; Reporting; Research; Self Efficacy; Social Environment; Structural Racism; Testing; Treatment outcome; Viral; Work; anti-racism; antiretroviral therapy; arm; base; community transmission; cost; diversity and inclusion; effectiveness outcome; effectiveness testing; ethnic minority population; experience; health equity; health inequalities; implementation intervention; implementation outcomes; implementation science; implementation strategy; improved; information system analysis; innovation; multilevel analysis; organizational climate; perceived discrimination; post implementation; primary outcome; racial and ethnic; racial disparity; racial minority; retention rate; secondary outcome; social cohesion; social organization; standard of care; therapy adherence; therapy development; tool

Abstract/ Project Summary: Despite the widespread use of effective antiretroviral therapy (ART), the HIV epidemic continues to impact racial and ethnic minority populations disproportionately. Although Black/African American persons account for 13% of the U.S. population, they account for 41% of new HIV diagnoses and experience the lowest rates of retention in HIV care and viral suppression (VS) compared to other racial/ethnic groups. Structural racism and discrimination (SRD) likely contribute to racial disparities in HIV outcomes. Although the outpatient setting is a vitally important aspect of care provision for PLWH, there are limited data on the impact of intra-organizational SRD on HIV outcomes. Longitudinal engagement in HIV care is needed for sustained VS, decreased community transmission of HIV. The organizational social context (OSC) includes organizational culture (organizational norms and values that drive quality of care), organizational climate (perception of the culture and how it impacts personal well-being), and workers' attitudes. Using a randomized controlled trial, we will implement ARC (Accessibility, Responsiveness, Continuity) to improve organizational behavior and reduce racial disparities in HIV outcomes for PLWH. ARC is an evidence-based intervention that uses three strategies (ARC principles, ARC component tools, and ARC mental models) to create OSCs that support the implementation of interventions to improve patient outcomes. Clinics will be randomized to ARC (n = 2) or standard of care (SOC; n= 2). Those assigned to ARC will address SRD occurring at the organizational level affecting care, including referral and treatment patterns for PLWH. A pre-implementation period will be followed by ARC and ARC-associated implementation strategies for 36 months and then a 12-month post-implementation period where we will continue to measure HIV outcomes in both arms. We will compare HIV outcomes, namely VS and retention in care, and intermediate outcomes, such as linkage to mental health treatment and staff turn-over in clinics assigned to ARC and SOC. We will also evaluate whether individual (self-efficacy, perceived discrimination) and organizational factors (OSC and cohesion of OSC measures) mediate the relationship between ARC, intermediate, and HIV outcomes. In preparation to the RCT, we will evaluate baseline OSC measures across 12 HIV clinics in Philadelphia and determine aspects of the OSC associated with VS and retention in care in a multi-level model adjusting for neighborhood SRD, patient-level factors, and clustering of patients nested in clinics and neighborhoods. We will then test the effectiveness of ARC in improving a primary outcome of VS and secondary outcome of retention in care at the end of the implementation period. We will examine the acceptability, sustainability, and cost of implementing ARC in outpatient HIV care. This research will advance understanding of the impact of SRD on HIV treatment outcomes and health services research and the implementation of a disseminable evidence-based practice aimed at reducing SRD.

摘要/项目摘要：尽管广泛使用有效的抗逆转录病毒疗法（ART）， 这一流行病继续不成比例地影响少数种族和族裔人口。黑人/非洲人 美国人占美国人口的13%，他们占新艾滋病毒诊断的41%， 与其他种族/族裔相比， 组结构性种族主义和歧视（SRD）可能会导致艾滋病毒结果的种族差异。 虽然门诊设置是一个至关重要的方面，护理提供艾滋病毒携带者，有有限的数据， 关于组织内SRD对艾滋病毒成果的影响。需要纵向参与艾滋病毒护理 持续的VS，减少艾滋病毒的社区传播。组织社会背景（OSC）包括 组织文化（推动护理质量的组织规范和价值观），组织氛围 （对文化的看法及其如何影响个人福祉）和工人的态度。使用 随机对照试验，我们将实施ARC（可及性，响应性，连续性）， 改善组织行为，减少艾滋病毒感染者结局的种族差异。ARC是一个 循证干预，采用三种策略（ARC原则，ARC组件工具，ARC 心理模型），以创建支持实施干预措施以改善患者结局的OSC。 诊所将随机分配至ARC（n = 2）或标准治疗（SOC; n= 2）。那些被分配到ARC的人将 解决在组织层面发生的影响护理的SRD，包括转诊和治疗模式， PLWH。在实施前阶段之后，将实施ARC和ARC相关的实施战略 36个月，然后是实施后的12个月，我们将继续测量艾滋病毒 两个武器的结果。我们将比较艾滋病毒的结果，即VS和护理保留，以及中间 结果，如与精神健康治疗的联系和分配给ARC和SOC的诊所的工作人员流动。 我们还将评估是否个人（自我效能，感知歧视）和组织因素 (OSC OSC措施的凝聚力）调解ARC，中间，和艾滋病毒之间的关系 结果。在准备随机对照试验时，我们将评估12个艾滋病诊所的基线OSC措施， 费城，并在多水平模型中确定与VS和护理保留相关的OSC方面 调整社区SRD、患者水平因素和嵌套在诊所中的患者聚集， 邻里关系然后，我们将测试ARC在改善VS的主要结局方面的有效性， 在实施期结束时继续接受护理的次要结果。我们会研究 在门诊HIV护理中实施ARC的可接受性、可持续性和成本。这项研究将推动 了解SRD对艾滋病毒治疗结果和卫生服务研究的影响， 实施旨在减少SRD的可推广循证做法。