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)，但艾滋病毒 流行病继续对种族和少数民族人口造成不成比例的影响。尽管黑人/非洲人 美国人占美国人口的13%，他们占新确诊艾滋病毒病例的41%， 与其他种族/民族相比，在艾滋病毒护理和病毒抑制(VS)方面的保留率最低 组。结构性种族主义和歧视(SRD)可能导致艾滋病毒结果中的种族差异。 尽管门诊设置是PLWH护理提供的一个至关重要的方面，但数据有限 关于组织内SRD对艾滋病毒结果的影响。需要对艾滋病毒护理进行纵向参与 对于持续的VS，减少了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 (对文化的认知及其如何影响个人福祉)，以及工人的态度。使用 随机对照试验，我们将实施ARC(可获得性、响应性、连续性)来 改善组织行为，减少PLWH在艾滋病毒结果中的种族差异。ARC是一种 使用三种策略(ARC原则、ARC组件工具和ARC)的循证干预 心理模型)，以创建支持实施干预措施以改善患者结局的OSC。 诊所将随机分为ARC组(n=2)或标准护理组(SOC；n=2)。分配给ARC的人将 解决在组织一级发生的影响护理的SRD，包括转诊和治疗模式 PLWH。在实施前阶段之后将实施ARC和与ARC相关的实施战略 36个月，然后是实施后的12个月，在此期间我们将继续测量艾滋病毒 双方都取得了成果。我们将比较HIV的结果，即VS和保留在护理中，以及中间 结果，例如与精神健康治疗的联系以及分配给ARC和SOC的诊所的工作人员移交。 我们还将评估个人(自我效能感、知觉歧视)和组织因素 (OSC和OSC措施的凝聚力)调节ARC、中间体和HIV之间的关系 结果。为准备随机对照试验，我们将评估12家艾滋病毒诊所的OSC基线措施。 Philadelphia，并在多水平模型中确定与VS和护理保留相关的OSC的各个方面 根据邻近的SRD、患者级别的因素以及嵌套在诊所和 邻里关系。然后我们将测试ARC在改善VS和VS的初步结果方面的有效性 在执行期结束时留住护理的次要结果。我们将研究 在门诊HIV护理中实施ARC的可接受性、可持续性和成本。这项研究将会取得进展 了解SRD对艾滋病毒治疗结果和卫生服务研究的影响以及 实施旨在减少自发性疾病的可传播的循证做法。