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

项目1：项目总结 在美国，烟草使用是导致死亡和残疾的主要原因，并与至少16 不同类型的癌症。尽管全国范围内的烟草使用率有所下降，但烟草使用已集中在 历史上被边缘化并在健康不平等中发挥关键作用的人口，核算 对于全因死亡率的34%和与吸烟有关的疾病的62%的社会经济梯度，包括 唇癌/口腔癌/咽癌、食道癌、喉癌、气管癌和肺癌。这些人群还经历了 有害的健康社会决定因素(SDOH)，经常与烟草使用同时出现，并有助于 获得和参与戒烟循证干预(EBI)的机会有限。因此， 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在贫困中的个人的影响。然而， 同时扩大烟草EBI覆盖范围的战略的效力和成本效益 停止和减轻SDOH对生活在持续贫困地区的个人的影响尚不清楚。 拟议的项目，通过在犹他州公平实施(REI-UT)，是一个务实的，多层次的 III型混合有效性--采用2x2析因实验设计的实施试验。REI-UT将是 与犹他州的6个社区卫生中心(CHC)系统和14个初级保健诊所共同开展 约1560名使用烟草并生活在持续贫困人口普查地区的患者。REI-UT利用一种创新的 捆绑解决有害的SDOH和烟草使用的方法，并利用无处不在的健康 循证干预(EBI)交付方式(即 犹他州烟草公司戒烟专线)以及传播和实施(D&I)战略。诊所和病人- D&I级策略利用广泛采用的基于移动电话的电子健康记录(EHR)功能 对话代理(CA)和基于电话的患者导航(PN)方法，以应对不良反应 SDOH和增加退出线的覆盖范围。通过利用现有的、免费的、 全国可用的用于戒烟的EBI。其目的是1)测试患者层面(CA和PN)的能力 扩大循证戒烟覆盖面(主要结果)的传播战略 通过戒烟热线为长期贫困的吸烟者提供治疗 人口普查区域。二次分析将检查SDOH服务范围的结果，其中 患者，并将评估(1)患者层面的CA和PN策略，以及(2)临床层面的策略(ASK- Adise-Connect[AAC]for SDOH)使用开机自检前设计；2)探索与范围相关的背景因素， 战略的采用、实施和可能的维护；以及3)确定成本效益 诊所和患者层面的策略，基于SDOH的退出线登记和接受服务。

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.