Background
Proposal of the health equity implementation framework
Implementation science framework: i-PARIHS
Health care disparities framework
Integrating the two frameworks
Key differences for implementation scientists
Application of health equity implementation framework
Methods
Study design and theoretical approach
Recruitment and data collection procedures
Quantitative data
Qualitative data
Measures
Quantitative data
Qualitative interviews
Analysis
Coding process
Results
Participants
Characteristic | N (%) |
---|---|
Age, in years | M = 61, SD = 8.54, Range = 38–69 |
Racial background | |
Black or African American | 11 (92) |
Biracial or Multiracial | 1 (8) |
Current employment status | |
Employed full-time | 1 (8) |
Employed part-time | 2 (17) |
Disabled | 4 (33) |
On SSI/SSDIa | 2 (17) |
Retired | 3 (25) |
Current living situation | |
Living on your own | 5 (42) |
Living with spouse/ domestic partner | 3 (25) |
Living with friends | 1 (8) |
Living with parents/family of origin | 1 (8) |
Living with roommates | 0 (0) |
Staying with people temporarily | 1 (8) |
Other (VA homeless program) | 1 (8) |
Highest education level | |
Some high school | 1 (8) |
High school graduate/GED | 6 (50) |
Technical school | 1 (8) |
Some college | 4 (33) |
Heard about new HCV treatment | 8 (67) |
Started/completed new HCV treatment | 5 (42) |
Miles traveled one-way to HCV treatment | M = 65.17, SD = 53.16, Range = 0–160, Mdn = 55 |
Main themes
HCV treatment facilitators: matrix of themes | ||
---|---|---|
Health Equity Implementation Framework element | Theme | Excerpt |
Innovation factors | ||
1) | HCV treatment regimen (daily pill for 12 weeks) and cost were acceptable to VA patients | No excerpt: When asked by the interviewer about pill form or cost of medicine at VA, all VA patients denied these being barriers. One exception is that pill form might require some medication management, which is addressed in the barriers section. The VA covered the cost of HCV treatment such that the medications would not cost money for VA patients. |
2) | Having the ability to try the treatment first was unimportant because of high cure rate and few side effects. | P 1: I just want to try [the new HCV treatment]. Like I said, I want to eliminate this, you know. I want whatever works… I want to live a little longer. I have fourteen grandchildren so I want to be around for them. |
Clinical encounter | ||
3) | Positive clinical encounters regarding HCV occurred when providers explained what HCV was, the new treatment, side effects, next steps, and answered VA patient questions. | P 9: [The local primary care clinic] took some bloodwork and told me [I had HCV]. they got me in to see the doctor in [VA medical center], and they went over the stuff with me and they started me on the medication. It happened pretty fast…I have no complaints. At first it scared me…like being around my grandchildren and stuff…and then they explained to me this and that, and I can be with the grandkids. If I have a cut and they have a cut or something, it can infect my grandchildren…And so until I got on that medication make sure I did not visit my grandchildren too often. We talked, and I asked her how long it would take me—actually, she called and was setting this stuff up, an appointment up for me when I was there in the office with her…I am happy with how it happened… They did a lot of bloodwork, and then when they got me in there and got me the medicine and then they gave me the results from last month, they told me about the drop [in HCV viral load] I had in it last month and I was happy because at least they are taking care of me. [The provider] talked with me…sits down and talks with me every time I get there. I talk to her like I am talking to you. I like her. |
4) | Wait time for an appointment was not an issue for any VA patient. | No excerpt: Once VA patients were offered a follow-up appointment to initiate HCV treatment, each VA patient denied that wait time for that specific appointment was too long. (Concerns about wait time to initiate treatment were expressed and reported in Table 3 findings of barriers). |
Recipient factors | ||
Patient factors | ||
5) | VA patients hoped there was no racial discrimination in VA | P 1: I hope color would not make a difference… If there’s a cure, then we should all have it. Black or white, it does not matter. Color does not matter. |
6) | VA patients were optimistic about treatment. | P 7: (When asked about barriers to getting the HCV treatment): I do not know because I want to have it. I do not see anything really getting in my way. |
7) | VA patients were eager for more HCV education and outreach. | P 8: Is [the treatment] going to work? Is it worth all the hassle going over there and getting medicine? One thing [that would make me likely to get the treatment] is if I am guaranteed it’s going to work. But I know that there is no guarantee. Another thing I would want to know more information on side effects… what I feel would be best would be for the VA to sit down one-on-one to discuss with a doctor that is familiar with the treatment, the side effects, and…if anybody that do this process get cured…you have different sites on the internet but the information is very limited. |
8) | VA patients reported positive trust in some VA providers who encouraged HCV treatment. | P 5: [There is] a [VA] licensed practitioner, who I put all my trust in, she always kept me abreast of everything... She offered, she said I seemed to be a good candidate for this treatment, if I wanted to accept it. And after she found out about the treatment, she informed me…she’s up to date on everything. I thank God for her. |
P 2: [What helped me decide to get treatment was my doctors] letting me know and telling me what medicine to take. I will do what the doctors told me to do. I trust them. | ||
Provider factors | ||
9) | VA patients perceived that most providers appeared to have a desire to help, reflected by being on time to appointments, explaining information in detail, and acting quickly on follow-up steps | P 5: I think that they go in and whoever the doctor is talks about the meds… hopefully they can get a practitioner like [my provider]. That makes a big difference when you have somebody that you are seeing that is actually concerned about you. Those that are there to receive a paycheck are not really worried about you, and I do not really find that with her. She does not have to be like that. She would call and say this is [provider], I am calling to check on you and see how you are doing. Many times I might forget to make an appointment, but she’ll call and remind me to check in with her. And that’s compassion, you know. You do not find that much. |
10) | Some VA providers were perceived as not having or enacting racial biases. | P 5: I think I am going to give [VA providers] the benefit on that question [about racial discrimination]. We have caring physicians, practitioners that are caring enough to know that…people of color have been unproportionally less with benefits of medical advancement and they see that this availability now is even more available for minority for the white, Caucasian. So now it’s been given to them more freely than it was back in say the 70s. |
Context factors | ||
Inner context: local level (clinics) | ||
11) | VA clinics offsets HCV stigma in society by protecting patient confidentiality and including HCV-positive patients in other general infectious disease clinics | P 6: (When asked about HCV stigma getting in the way of treatment) No… I go to the clinic and the woman calls my name. She calls my name, but they do not know what I am going back there for. That’s why I said I do not have no problems going to the doctor because it’s private. |
Inner context: organizational level (VA only) | ||
12) | VA patients perceived VA used best medicine and genuinely wanted to help VA patients | No excerpt: When asked directly, “do you think the VA uses the best medicine and wants to help Veterans?”, each participant said yes. |
Outer context (both VA and outside VA) | ||
13) | VA patients reported some HCV treatment materials circulating | P 4: The only information I have—have heard it on T.V., you know, commercials about Hep C. |
14) | Positive testimonials about HCV treatment made VA patients more likely to want or to try the treatment | P 1: [My friend] just had [the treatment], and he was telling me that they treated him for twelve weeks with some medicine…It was through another clinic…his outcome was great…They were giving him some kind of pills, you know. And he told me, man, matter of fact he told me the other day, he said man, I got rid of that Hepatitis C in my blood… That made me feel great, you know. That made me want it even more, you know. |
15) | Positive testimonials about healthcare in general made VA patients more open to HCV treatment | P 10: Most of my friends and family go to the hospital and see doctors…they go so it’s got to be positive. I go with my sister twice a week to [the doctor]. So most of my friends are up in age with me, and we all go to doctors and stuff so they go to the hospital…I go regularly when I need to be seen, you know. |
HCV treatment barriers: matrix of themes | ||
---|---|---|
Health Equity Implementation Framework domain | Theme | Excerpt |
Innovation factor | ||
1) | VA patients need a medication reminder system to support adherence. | P 6: I’d forget [to take the HCV pill] because I do not take [the pill] at the same time… I wasn’t in the habit of taking it at the same time…So sometimes I would not remember if I took it…I got one of them boxes…You know how they have got the package where you punch them out. The packet does not have that. |
Clinical encounter | ||
2) | Negative clinical encounters occurred when providers did not offer HCV treatment, follow up on results of bloodwork, or explain rationale for decision regarding HCV treatment. | P 1: (from a VA patient who had not received HCV treatment, but tested positive at a recent appointment) [My VA provider] did tell me about this new drug…they had been advertising it on T.V. She asked if I had seen that commercial on T.V. about the drug they are using on Hepatitis C…I said, yes. She said do not believe it because it does not work…why would they advertise something like this on television if it does not work? Why would a doctor say something like this? It made me feel disgruntled…Because I am hearing this and they are saying it cures Hepatitis C in a pill form, and then when I talked to her...She told me something totally different...She could have explained it to me why it does not work, you know. |
Recipient factors | ||
Patient factors | ||
3) | VA patients lack knowledge of HCV symptoms. | P 4: (When asked what the VA could do to improve HCV treatment) Well, I would like to know exactly what is Hep C and what are the symptoms. |
4) | VA patients reported transportation barriers to HCV treatment. | P 10: I think [the VA] should pick people up at their house instead of having them meet at a place because like right now I do not have no transportation and the bus leaves at six o’clock in the morning so I have to get a ride from somebody around five o’clock…I do not like bothering people that time of the morning, you know. |
5) | VA patients question trust in some providers. | P 5: I go to the VA doctor, and I guess they know best. I mean, they always want what is best for you, right? |
P 6: [I would have a problem] maybe trusting the VA doctors. I guess they really do not treat Veterans like they should and I am just disappointed. I do not know. | ||
Provider factors | ||
6) | VA patients reported some VA providers lacked expertise about HCV treatment. | P 11: They need some more specialist. My Hepatitis C, they should have treated that. [The new HCV treatment] was free, but it just took so long. I had to go through all this red tape because it was so confusing, not just to me but it was confusing to them too. That’s why I say they have got to be better trained, you know. |
7) | VA patients reported some VA providers appear to have racial biases. | P 7: Now there was a doctor…he mentioned treatment about Hepatitis C, but he told me if I smoked marijuana I could not get it. I just thought it was old, mean man that did not like the fact that I smoke marijuana…I wasn’t sure that he was going to try to get me treatment for it anyway…I take responsibility for [smoking]…I do not want to make him seem like a bad seller…even though I do not think what he was telling me was right…I have got mixed feelings about it… with all due respect, he’s an old white man and I am down here in the South and I have reservations about that. Not that I do not have trust for the older ones… I just got that impression about this old guy… because I am in the racial South, and if I can remember correctly, he did not really touch me. He just talked to me, and he was kind of grouchy…it’s like he had an attitude, and it could have been some stress from his working. I really do not know, but an old, white man from down here in the South I can easily get the impression that he do not give two cents about black men down here or anywhere. Now that might just be my prejudice, but I do not think so. |
Context factors | ||
Inner context: local level (clinics) | ||
8) | VA patients reported stories about lack of follow-up to VA patient after VA patient tested positive for HCV. | P 1: What’s hard is the doctors in [the VA medical center] had never started the treatment, you know, sent it to the [community based outpatient clinic] here…She knew I had this here. I did have bloodwork. Why has not my treatment appeared that you said you were going to prescribe for me? Why have not they come to the clinic yet, and why have not I been told about it? |
Inner context: organizational level (VA only) | ||
9) | Negative testimonials from family/friends about racial discrimination at VA made VA patients hesitant to go to VA or trust providers. | P 6: [VA doctors] do not concern themselves with things that are important because they treat you just like I have seen in the black community most people will not go to the VA for medical reasons not because the doctors do not know what they are doing because they are not going to get the service they’ll get at a private practitioner. Well, with the blacks there is a lack of trust because most everybody they know – my dad, he was a World War II Veteran, and they treated him like, you know, like he was nothing. I remember how he was treated…I had not gone to the VA clinic for anything…[because of] I have seen the way they treated him. |
10) | Negative VA experiences are generalized to all VA care. | P 6: [The VA provider just sits] down in there and look at your chart. She asks you about your medicines…asks about the doses. She do not check and see if your condition has changed…if you say, oh, it still hurts, she’s going to increase the medicine. They just write a prescription and you can go...I got a cough. They do not look down your throat to see what it is causing the problem…I can be taking Benadryl for a cough and have throat cancer. The services at the VA is piss poor. |
11) | VA patients reported there was not enough HCV treatment at local community-based outpatient clinics and they had to travel to larger VA medical centers. | P 6: They should not make appointments that you have to go out of town for…how can you give me a consult to go to [another state] when I can barely get to the clinic here? They need to do something with upgrading the infrastructure here. |
Outer context (both VA and outside VA) | ||
12) | HCV stigma in society made VA patients less likely to reach out to share recovery story or get support in obtaining treatment (e.g., transportation). | P 8: I did not tell anybody and nobody asked [about me getting HCV treatment]. I keep to myself. I am not an outgoing person. People like to talk too much…people form opinions about things. ‘He must have been shooting dope or he must be messing with whatever.’ I keep things to myself so that way I will not have that stigma about how I got [HCV]. |
13) | VA patients reported there are not enough HCV educational materials circulating, especially in rural areas. | P 1: Now, [media] should be something they should do something about. They should advertise that. Let more people know about [HCV]. Is it a disease? they have done a lot about the Zika virus. let us do something about [HCV]… publications, news, radio…However they can get it across to the people and make them aware of this. |
P 8: To be honest with you, recently, I am just understanding what Hep C really is…I always felt Hepatitis C was someone using a utensil or something that wasn’t clean or a blood transfusion. Previously, that’s where I felt Hepatitis came from…I wasn’t really aware…I grew up in a rural area. Drugs were not relevant there. |