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：尽管有效的抗逆转录病毒疗法（ART）得到广泛使用，但艾滋病毒 这一流行病继续对少数种族和族裔人口产生不成比例的影响。虽然黑人/非洲人 美国人占美国人口的 13%，占新增艾滋病毒诊断人数的 41%， 与其他种族/族裔相比，艾滋病毒护理和病毒抑制 (VS) 的保留率最低 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。 尽管门诊环境是为感染者提供护理的一个至关重要的方面，但数据有限 组织内 SRD 对 HIV 结果的影响。需要纵向参与艾滋病毒护理 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 （对文化的看法及其如何影响个人福祉）以及员工的态度。使用 随机对照试验，我们将实施 ARC（可访问性、响应性、连续性） 改善组织行为并减少艾滋病毒感染者感染结果的种族差异。 ARC 是一个 使用三种策略（ARC 原则、ARC 组件工具和 ARC 心理模型）来创建 OSC，支持实施干预措施以改善患者的治疗结果。 诊所将随机接受 ARC (n = 2) 或标准护理 (SOC; n = 2)。分配给 ARC 的人员将 解决组织层面发生的影响护理的 SRD，包括转诊和治疗模式 感染者。预实施期之后将是 ARC 和与 ARC 相关的实施战略 36 个月，然后是实施后 12 个月，我们将继续测量艾滋病毒 双臂的结果。我们将比较 HIV 结果，即 VS 和保留护理以及中间结果 结果，例如与心理健康治疗的联系以及分配给 ARC 和 SOC 的诊所的员工流动率。 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 措施的凝聚力）调节 ARC、中间体和 HIV 之间的关系 结果。在准备 RCT 时，我们将评估 12 个 HIV 诊所的基线 OSC 措施 费城并在多级模型中确定与 VS 和护理保留相关的 OSC 的各个方面 调整邻里 SRD、患者层面的因素以及诊所内的患者聚集情况 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，以及 实施期结束时保留护理的次要结果。我们将检查 在门诊 HIV 护理中实施 ARC 的可接受性、可持续性和成本。这项研究将推进 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的可传播的循证实践。