Multi-level interventions for addressing tobacco cessation and SDOH in Community Health Centers (CHCs)

项目1：项目概要 烟草使用是美国死亡和残疾的主要原因，与至少16种疾病有关。 不同类型的癌症。虽然全国范围内的吸烟率有所下降，但烟草使用集中在 在历史上被边缘化并在卫生不公平方面发挥关键作用的人口， 34%的社会经济梯度的全因死亡率和62%的吸烟相关疾病，包括 唇/口腔/咽、食道、喉、气管和肺的癌症。这些人也经历了 健康的不利社会决定因素（SDOH），经常与烟草使用同时发生， 获得和参与戒烟循证干预措施（EBI）的机会有限。因此，委员会认为， 同时解决SDOH和烟草使用问题可能会解决参与EBI戒烟的障碍 并最终减少烟草使用对生活贫困的个人的影响。但 同时扩大烟草EBI覆盖范围的战略的有效性和成本效益 目前尚不清楚在生活在持续贫困地区的个人中停止和减轻SDOH的影响。 拟议的项目，通过公平实施在犹他州（REI-UT），是一个务实的，多层次的 III型混合重复性-采用2x2析因实验设计的实施试验。REI-UT将是 在犹他州的6个社区卫生中心（CHC）系统和14个初级保健诊所进行， ~1560名吸烟并生活在持续贫困人口普查区的患者。REI-UT采用创新的 捆绑式方法，同时解决不利的SDOH和烟草使用，并利用无处不在的健康 信息技术/远程保健的循证干预（EBI）交付模式（即，的 犹他州戒烟热线）以及传播和实施（D&I）战略。诊所和病人- 一级D&I战略利用广泛采用的电子健康记录（EHR）功能，基于移动的电话 会话代理（CA）和基于电话的患者导航（PN）方法，以解决不良 SDOH和增加退出线的范围。通过利用现有的、免费的、 全国范围内提供的EBI用于戒烟。目的是1）测试患者水平（CA和PN）的能力 提高循证戒烟覆盖率（主要结局）的传播策略 通过戒烟热线为吸烟和生活在持续贫困中的CHC患者提供治疗 人口普查区。次级分析将检查这些服务中SDOH服务范围的结果 患者，并将评估（1）患者水平CA和PN策略，以及（2）诊所水平策略（询问- 建议-连接[AAC]为SDOH）使用前后设计; 2）探索与达到相关的背景因素， 战略的采纳、实施和潜在的维护;以及3）确定 基于SDOH退出线登记和服务接收的诊所和患者级别策略。

PROJECT 1: PROJECT SUMMARY Tobacco use is the leading cause of death and disability in the United States, and is associated with at least 16 different types of cancers. Though nationwide rates have declined, tobacco use has become concentrated in populations that have been historically marginalized and plays a critical role in health inequities, accounting for 34% of the socioeconomic gradient in all-cause mortality and 62% in smoking related diseases, including cancers of the lip/oral cavity/pharynx, esophagus, larynx, trachea, and lung. These populations also experience adverse Social Determinants of Health (SDOH), which frequently co-occur with tobacco use, and contribute to limited access and engagement with evidenced-based interventions (EBIs) for tobacco cessation. Consequently, addressing SDOH and tobacco use concurrently may address barriers to engaging in EBIs for tobacco cessation and ultimately reduce the impact of tobacco use among individuals living in poverty. However, the effectiveness and cost effectiveness of strategies to concurrently increase the reach of EBIs for tobacco cessation and mitigate the effects of SDOH among individuals living in persistent poverty areas is unknown. The proposed project, Reach through Equitable Implementation in Utah (REI-UT), is a pragmatic, multilevel Type III Hybrid Effectiveness-Implementation trial with a 2x2 factorial experimental design. REI-UT will be conducted with 6 Community Health Center (CHC) systems and 14 primary care clinics across Utah that serve ~1560 patients who use tobacco and live in persistent poverty census tracts. REI-UT utilizes an innovative bundled approach to address adverse SDOH and tobacco use concurrently, and leverages ubiquitous health information technology/telehealth for both the evidence-based intervention (EBI) delivery modality (i.e., the Utah Tobacco Quit Line) and for dissemination and implementation (D&I) strategies. The clinic and patient- level D&I strategies utilize widely adopted Electronic Health Record (EHR) capabilities, mobile phone—based conversational agents (CA), and telephone–based patient navigation (PN) approaches to address adverse SDOH and increase the reach of the Quit Line. Sustainability is enhanced by utilizing an existing, free, nationally available EBI for tobacco cessation. The aims are to 1) Test the ability of patient level (CA & PN) dissemination strategies to increase the Reach (primary outcome) of evidence-based tobacco cessation treatment delivered via the Quit Line among CHC patients who use tobacco and live in persistent poverty census tracts. Secondary analyses will examine the outcome of Reach of services for SDOH among these patients, and will evaluate both (1) patient level CA and PN strategies, and (2) clinic level strategy (Ask – Advise – Connect [AAC] for SDOH) using a pre-post design; 2) Explore contextual factors related to the Reach, Adoption, Implementation, and potential Maintenance of strategies; and 3) Determine cost-effectiveness of clinic and patient level strategies based on Quit Line enrollment and receipt of services for SDOH.