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Stakeholder Perspectives on MAPS

Sanchez, Amanda L. PhDa,b,c; Hoskins, Katelin PhDa,b,c; Pettit, Amy R. PhDd; Momplaisir, Florence MDe,f; Gross, Robert MDe,f; Brady, Kathleen A. MDg; Hoffacker, Carlin BAh; Zentgraf, Kelly MSa,b; Beidas, Rinad S. PhDa,b,c,i,j,k

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1, 2022 - Volume 90 - Issue S1 - p S190-S196
doi: 10.1097/QAI.0000000000002979

Abstract

  • Evidence-based innovation: CHW-delivered managed problem solving (MAPS) to increase medication adherence and care retention.
  • Innovation recipients: People with HIV (PWH) in Philadelphia County.
  • Setting: Philadelphia County Ryan White clinics.
  • Implementation gap: Uptake of behavioral intervention (MAPS) is low in community health clinics.
  • Primary research goal: Identify determinants of implementation.

INTRODUCTION

The Ending the HIV Epidemic (EHE) initiative seeks to reduce new HIV infections in the US by 90% by 2030, a goal that necessitates people with HIV (PWH) to be virally suppressed and retained in care.1 Philadelphia County is among 48 prioritized EHE counties given: (1) high rates of new HIV diagnoses annually; (2) 81% of PWH have been linked to care but only 53% are retained in care and only 67% have achieved viral suppression.2 In line with EHE, the Philadelphia Department of Public Health (PDPH) has set a goal for 92% of PWH in care to achieve viral suppression.2 This will require implementation of evidence-based practices targeting viral suppression and care retention. These efforts can serve as an exemplar for the national EHE initiative.

Managed problem solving (MAPS) is a CDC-endorsed evidence-based intervention to increase medication adherence and viral suppression in PWH. MAPS uses a collaborative problem-solving approach,3 partnering with the patient through 5 steps: (1) identifying barriers to adherence, (2) brainstorming to generate potential solutions, (3) decision-making and developing a plan of action, (4) implementing the plan, and (5) evaluating and modifying the plan as necessary.4 Sessions focus on skill-building, tailoring solutions to specific individual needs, and empowering people to manage their own health. MAPS was delivered by college graduate-level interventionists in a randomized controlled trial, testing it among treatment-naive and treatment-experienced populations. MAPS significantly increased medication adherence and viral suppression in both patient groups 1 year after intervention.4 Unfortunately, MAPS adoption in the community has been low. Conversations with PDPH and clinic leaders have indicated that MAPS requires adaptation for delivery by nonmedical specialists (ie, task-shifting) because of time constraints among existing clinic staff. One way to address this barrier is to use lay community health workers (CHWs), who function as a bridge between patients and the health care system, to deliver MAPS. CHWs have improved HIV outcomes and other health-related outcomes in low- and middle-income countries and offer a promising avenue for implementation in under-resourced communities in the US.5

To maximize the likelihood that MAPS is equitably deployed into practice, a more nuanced understanding of the multilevel implementation context is essential.6 The current study leverages a partnership between PDPH and Ryan White-funded clinics in Philadelphia to assess barriers and facilitators to CHW-delivered MAPS implementation as part of pre-implementation contextual inquiry.6 Although traditional contextual inquiry and qualitative analyses can take years, rapid analytic techniques permit inquiry to inform implementation planning more efficiently.7–11 Moreover, research suggests that framework-guided rapid qualitative analyses can yield similar findings to in-depth qualitative analyses, highlighting the potential for rapid methods to produce valid, actionable outputs for stakeholders.12 Thus, we used an innovative rapid qualitative approach infrequently applied in implementation science to analyze stakeholder feedback to more quickly inform implementation mapping, a systematic process for the development of implementation strategies that will be tested in a subsequent hybrid type 2 effectiveness-implementation trial.12,13

METHODS

Participants

Participating stakeholders were from 4 groups collaboratively chosen in consultation with PDPH leadership and the study team: prescribing clinicians; clinical team members who do not prescribe medications (ie, behavioral health consultants, medical case managers, and outreach coordinators); clinic administrators; and policymakers. Purposive sampling14 was used to recruit participants within each stakeholder group and across the 13 Ryan White-funded clinics in Philadelphia County. All procedures were approved by the City of Philadelphia Institutional Review Board and informed consent was obtained from all participants, who were offered a $50 gift card.

Procedures

Guided by the Consolidated Framework for Implementation Research (CFIR),15 semistructured individual interviews were conducted from January to May 2021 to understand implementation barriers and facilitators. CFIR domains included: (1) intervention characteristics (ie, MAPS characteristics); (2) outer setting (ie, the economic, political, and social context within which an organization exists); (3) inner setting (ie, the organization); (4) characteristics of CHWs and other staff involved in implementation; and (5) the potential implementation process. Two research team members (AS, AP) piloted the interview guides and conducted initial interviews. Research coordinators were trained to conduct subsequent interviews and were observed during initial interviews.

Data Collection and Analysis

Data were collected and analyzed using rapid qualitative analysis techniques9–12 adapted for the project timeline and deliverables. Interviews were semistructured with approximately 17 questions, were conducted over video or telephone, and lasted approximately 1 hour. All interviews were recorded with permission and stored in REDCap. The research team developed a structured summary template to organize and condense the data (Supplemental Digital Content, https://links.lww.com/QAI/B844). Summary template domains were based on each key element within the interview (eg, patient referral procedures, workflow challenges, team communication). Immediately following each interview, the interviewer completed the summary template. Summaries were designed to be organized, thorough, and descriptive, and the average summary length was 2 pages.

First, summary template content was transferred into matrix displays to streamline synthesis (Supplemental Digital Content, https://links.lww.com/QAI/B845).9–12 Within the matrix, the columns listed the summary template domains, and stakeholder groups (ie, individual cases) were arranged in the rows.

Each matrix cell reflected a unique stakeholder's response.10 Specific transcripts and audio recordings were revisited during matrix analysis to increase clarity and gain additional context. Second, 2 members of the team (A.S., K.H.) used the matrix cells to group determinants of implementation (ie, barriers and facilitators to MAPS implementation). Third, determinants of MAPS implementation were mapped onto main categories along an implementation pathway. Implementation pathway categories reflect the sequential process of implementing MAPS within each clinic and were generated from temporal linkages across the determinants (ie, when barriers or facilitators might present during the implementation process). Core determinants were organized within each category. Memos were maintained to detail analytic insights, and team members met frequently to discuss patterns.

RESULTS

Characteristics of the 31 participants are presented in Table 1. Most stakeholders (81%) were women and approximately half identified as being from diverse racial and ethnic backgrounds.

TABLE 1. - Stakeholder Characteristics (N = 31)
n (%)
Stakeholder group
 Prescribing clinicians 6 (19.3)
 Other clinical team members* 14 (45.2)
 Clinical administrators 7 (22.6)
 Policymakers 4 (12.9)
Gender identity
 Female 25 (80.7)
 Male 6 (19.3)
Racial/ethnic identity
 Black/African American 9 (29.0)
 Hispanic/Latinx 4 (12.9)
 White Hispanic/Latinx 2 (6.5)
 White non-Hispanic/Latinx 15 (48.4)
 Prefer not to disclose 1 (3.2)
M (SD)
 Age 44.9 (11.8)
 Years in field 11.5 (8.3)
*“Other clinical team members” included team members who do not prescribe medications (ie, behavioral health consultants, medical case managers, and outreach coordinators).

Figure 1 illustrates the synthesized categories as key points along the implementation pathway, from pre-implementation to implementation. Table 2 presents the categories, key determinants within each category, and their associated CFIR domains. Categories included:

F1
FIGURE 1.:
MAPS implementation pathway. *Pre-implementation stages included introducing MAPS and integrating the CHW with the care team. The implementation stage includes identifying and referring patients for MAPS, connecting patients with CHWs, delivering MAPS, and coordinating care between CHW and care team. The outer context determinants are reflected surrounding the implementation pathway.
TABLE 2. - Key Determinants and CFIR Domains/Constructs
Determinant Definition CFIR Domain/Construct
Introducing MAPS to the clinic
 Leadership and staff buy-in for CHW/MAPS Clinic leadership and staff agreement and support for CHW-delivered MAPS Inner setting: leadership & staff engagement
 Team expectations for CHW/MAPS Clear expectations from clinic team about the CHW role and purpose/utility of MAPS intervention and messaging related to added benefits of MAPS Intervention characteristics: relative advantage
Integrating CHW with the team
 CHW onboarding and training process Process for orienting and training the CHW in clinic-level processes and MAPS delivery Process: planning
 CHW as core team member Integration of CHW as a valued member of the care team Process: planning
 Workflow and role clarity across the team Identification of scope, boundaries, and responsibilities for new CHW role in relation to other team members to promote clear sequences of tasks within the clinic team Process: planning
 Clinic-level consultation/supervision for CHW CHW supervision (ie, both managerial and clinical) of CHW by clinic administrator and research team Process: planning
 CHW presence on-site Physical presence of the CHW on-site and within clinics Inner setting: networks & communications
 Physical space constraints Limitations on physical space for MAPS delivery and/or CHW touchdown area Inner setting: available resources
Identifying and referring patients for MAPS
 Structure of existing processes for identification and referral Use of existing clinic processes (ie, established electronic health record procedures) to identify and refer patients for MAPS Inner setting: networks & communications
 Provider, outreach coordinator, administrator identification Team member (ie, provider, outreach coordinator, MCM, administrator) identification of patients for MAPS referral to augment exclusively data-driven processes Inner setting: networks & communications
Connecting patients and CHWs
 CHW scheduling and availability CHW work schedule and accessibility for patients and team members Process: planning
 Initial contact between patient and CHW First connection between patients and CHWs (eg, building trust and demonstrating the CHW is part of the care team) Process: planning
 CHW characteristics Characteristics of the CHW (eg, demographics, experiences, attitudes, skills) Characteristics of individuals: other personal attributes
 Navigation of stigma/fostering trust/individual level stigma CHW mitigation of stigma (ie, co-occurrence of stereotyping, separation, status loss, and discrimination) in forming relationships with patients Characteristics of individuals: other personal attributes
Delivering MAPS
 MAPS characteristics Components and features of MAPS intervention Intervention characteristics: adaptability
 Flexibility of MAPS delivery Multiple options for delivery of MAPS (eg, time, location, method) Intervention characteristics: adaptability
 Patient’s perceptions of CHW-delivered MAPS Perceived burdens/costs or benefits conferred by MAPS engagement Intervention characteristics: complexity
Coordinating care between CHW and team
 Care coordination/clear communication of patient needs Communication between CHW and team members about MAPS engagement Inner setting: networks & communications
 Existing technology platforms for communication Use of current technology (ie, epic) for MAPS-related communication Inner setting: networks & communications
 Appropriate cross-referral CHW referral of patients to additional services (ie, behavioral health) when indicated Inner setting: networks & communications
 CHW knowledge of cross-clinic processes CHW knowledge of unique processes/procedures across assigned clinics Inner setting: networks & communications
 Dissemination of effectiveness & outcomes Sharing of MAPS positive outcome data with clinic team by CHW Intervention characteristics: relative advantage
 Ongoing CHW support and supervision Ongoing CHW support and supervision (beyond initial training) by clinic staff to facilitate effectiveness and coordination of care Inner setting: networks & communications
* Sociopolitical context
 Structural racism A system in which public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways to perpetuate racial group inequity Outer setting
 Structural stigma Societal-level conditions, cultural norms, and institutional practices that constrain opportunities, resources, and wellbeing Outer setting
 Poverty Lack of financial resources and essentials for a minimum standard of living Outer setting
 Technology disparities Differences in access to technology (eg, phone, internet) that affect treatment Outer setting
 Intersectional marginalization Experiences of discrimination and systemic exclusion because of the specific intersection of individuals' multiple identities Outer setting
 Medical hierarchy Systems of power, privilege, and authority in health care that may manifest with prescribing clinicians having higher status Outer setting
 Representation of shared identity Identification of common qualities/characteristics across clinic staff and patients Outer setting
 Comprehensive social services Referral and linkage to valuable social services, including medical insurance, housing, utility payments, food, and mental health therapy Outer setting
 Community and family supports Access to community resources and family supports that provide healthy connection Outer setting
 Norms of respect and dignity in HIV care Sensitivity, responsivity, and respect deeply embedded within HIV care and treatment Outer setting
*We were able to identify the domain but not construct for the sociopolitical context determinants.

Introducing MAPS to Clinics

The importance of leadership buy-in, expectations for CHWs and MAPS that included messaging within clinics (eg, introducing MAPS as an added resource and support for clinic and patients versus an added burden), and education for the whole team on both MAPS and the CHW role to promote understanding of added value were identified as important determinants. Stakeholders emphasized the importance of having champions for MAPS, especially physicians and clinic leadership, for successful adoption.

Integrating CHWs Within the Team

CHW onboarding and training processes (eg, training in electronic medical record systems and clinic policies, cultural competency, HIV treatment), the CHW as a core team member, and role clarity across the team, especially between the CHW and medical case manager, were key determinants for integrating CHWs within the team. In addition, CHW supervision or consultation by clinic staff (versus outside/centralized supervision only) was noted as an important factor for integration. Furthermore, stakeholders discussed the value of having CHWs present in the clinic, especially for standing meetings, and the use of existing methods (eg, texts, team meetings) to facilitate cohesion. Despite the expressed desire for CHWs to be present in the clinic, physical space limitations were acknowledged as a potential barrier.

Identifying and Referring Patients for MAPS

The use of existing processes for identification and referral of eligible patients (eg, data-generated lists, quality improvement reports) along with staff identification were identified as important determinants. Stakeholders noted the need for additional review of automated (data-based) referrals by clinic staff because of their knowledge of and relationships with patients.

Connecting Patients and CHWs

Flexibility of CHW scheduling, availability to accommodate patient preferences, and establishing initial contact with the CHW (eg, building trust and demonstrating to the patient that the CHW is indeed a key member of their care team) were identified as important determinants. CHW characteristics were also noted as important (eg, representative of the community regarding race/ethnicity, gender identity and/or neighborhood context; lived experience; and ability to reduce stigma and foster trust).

Stakeholders noted the need to frame MAPS to the patient as an additional resource or support rather than as a requirement, to reduce perceived burden.

Delivering MAPS

MAPS characteristics and flexibility of delivery (eg, time, location, and method) were identified to be common determinants. Specifically, several MAPS characteristics were noted as potential barriers (eg, length, number of sessions, language availability, literacy demands), yet MAPS characteristics were more frequently discussed as facilitators (eg, patient-centered and valuing patients' voices, structured, focused specifically on retention and adherence). Stakeholders discussed the unique roles of CHWs and MAPS to “partner with” patients to support them in engaging in treatment. Potential patient burden related to multiple medical appointments was an additional determinant; however, previously discussed facilitators such as staff communication, role clarity, and framing MAPS as an additional support were cited as ways to ameliorate this potential barrier.

Coordinating Care Between the CHW and the Treatment Team

Consistent communication across team members regarding patients' needs, using existing technology platforms and processes for this communication, appropriate cross-referral to team members with other skills and responsibilities, and CHW knowledge of clinic processes were identified as important determinants to successful MAPS implementation. Stakeholders also suggested that dissemination of effectiveness data to the clinic team would facilitate support for MAPS.

In addition, stakeholders highlighted the importance of ongoing CHW support and supervision (beyond initial training) as facilitating effectiveness and coordination of care.

Outer Context

Stakeholders indicated the presence of several outer context determinants that perpetuate disparities, including structural and systemic racism that reinforces HIV-related stigma, poverty, access to technology, and intersectional marginalization. Medical hierarchy and imbalances of power between prescribing clinicians and other staff and patients, was also a common determinant. To mitigate these factors, participants expressed a desire for more staff from underrepresented communities including Black and Latinx, gender or sexual minority, bilingual, and individuals with lived experiences to increase representation of shared identities between patients and providers, enhance connections to patients, and reduce detrimental power dynamics. Several other determinants were noted as facilitators for patients including comprehensive social services, community and family supports, and norms of respect and dignity in HIV care.

DISCUSSION

The current study used an innovative rapid qualitative analytic approach to efficiently center stakeholder input in the process of designing implementation strategies to increase use of an evidence-based behavioral intervention for medication adherence and care retention.

Stakeholder input generated key steps for an implementation pathway and associated determinants. This feedback will serve as inputs into implementation mapping13 to determine the implementation strategies needed to ensure the equitable and effective implementation of MAPS in clinics serving PWH across Philadelphia County, and these methods offer a blueprint for generating and analyzing local input elsewhere.16 In particular, stakeholders underscored the importance of cohesion and communication when adding a new clinical team member and offering a new intervention, suggesting that implementation strategies focused on these goals will be central to successful rollout. These determinants are key inputs for a working logic model organized by the Consolidated Framework for Implementation Research. Implementation strategies that conceptually match determinants will then be identified. For example, implementation strategies will likely include identifying champions to address the determinant related to leadership and staff buy-in, and revising professional roles to target workflow and role clarity across the team. Interview participants will be invited to attend stakeholder meetings to operationalize the proposed implementation strategies specific to their local clinic contexts.16

Stakeholders also viewed MAPS as offering added value to the HIV care continuum and noted that delivery by CHWs may mitigate stigma by incorporating staff who can connect and communicate with patients based on common experiences.17,18 This is important for increasing equity in health care, as stigma has been shown to strengthen inequities among those with marginalized identities (ie, class, race, gender, sexual orientation) and also has been found to moderate the effectiveness of psychological interventions.17,18 Stakeholders highlighted that the CHW-delivered MAPS approach, which focuses on partnering with the patient and centering their voice, may mitigate asymmetrical power dynamics that are often inadvertently embedded within patient–clinician relationships. This important contextual information will aid in the development of equity-informed implementation strategies.19–21

Limitations include lack of patient and CHW involvement in this phase of contextual inquiry. Future work will include the perspectives and experiences of those delivering and receiving the intervention. Second, results may be more generalizable for urban settings and may not speak to unique challenges of rural or suburban clinics serving PWH.

This study provides insights on determinants to consider when delivering evidence-based behavioral interventions in clinics serving PWH, especially in urban settings. Moreover, it demonstrates the use of a systematic process for rapid and rigorous extraction of determinants to inform implementation strategy planning. This study is one of the first to apply these methods to HIV care delivery and thus advances implementation research within HIV care and offers insights for national implementation efforts associated with EHE.

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Keywords:

implementation science; HIV care; rapid qualitative analyses; retention; adherence; community health worker

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