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），但艾滋病毒还是 流行病继续对种族和少数民族的影响不成比例。虽然是黑人/非洲人 美国人占美国人口的13％，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）可能导致艾滋病毒结局的种族差异。 尽管门诊环境是PLWH护理提供的重要方面，但数据有限 关于组织内SRD对HIV结果的影响。需要纵向参与艾滋病毒护理 对于持续的与艾滋病毒的社区传播减少。组织社会背景（OSC）包括 组织文化（组织规范和推动护理质量的价值），组织气候 （对文化的感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（可访问性，响应能力，连续性） 改善组织行为并减少PLWH的HIV结果中的种族差异。弧线是一个 使用三种策略的循证干预措施（ARC原理，ARC组件工具和ARC 心理模型）创建支持实施干预措施以改善患者预后的OSC。 诊所将被随机分为ARC（n = 2）或护理标准（SOC; n = 2）。分配给弧的人将 地址在组织一级发生的SRD影响护理，包括转诊和治疗模式 plwh。实施前将是ARC和ARC相关的实施策略 36个月，然后在实施后12个月，我们将继续衡量艾滋病毒 两臂的结果。我们将比较HIV的结果，即VS和保留在护理中，并中等 结果，例如与精神健康治疗的联系以及分配给ARC和SOC的诊所的员工转折。 我们还将评估个人（自我效能，感知歧视）和组织因素是否 （OSC和OSC测量的凝聚力）介导弧，中级和HIV之间的关系 结果。为了准备RCT，我们将评估12个HIV诊所的基线OSC措施 费城并确定与VS相关的OSC的各个方面，并在多层模型中保留了护理 调整邻居SRD，患者级因素以及嵌套在诊所和 社区。然后，我们将测试ARC在改善VS的主要结果方面的有效性 在实施期结束时保留护理的次要结果。我们将检查 在门诊艾滋病毒护理中实施弧的可接受性，可持续性和成本。这项研究将进步 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SRD的循证实践的实施。