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IMA 04-417 – QUERI Project

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IMA 04-417
Collaboration Support for Academic Expert in Implementation
Allen L. Gifford MD
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA
Bedford, MA
Funding Period: February 2005 - January 2007

BACKGROUND/RATIONALE:
As the largest provider of HIV care in the United States, the VHA depends on continuing advancements and innovations in the organization, delivery, and quality of care for veterans with and at risk for HIV. Advances in VHA social sciences can facilitate implementation and bolster sustainability. The QUERI in HIV/AIDS (QUERI-HIV) aims to improve the quality of care of VA patients infected with HIV by comprehensively defining optimal care; better understanding the impediments to such care at the organization, provider, and patient levels; and articulating and implementing evidence-based quality improvement (QI) interventions within clinical practice. As part of an ongoing effort to expand implementation research capacity, the QUERI-HIV Coordinating Center will undertake a two-year collaboration with Elisa J. Sobo, PhD, an academic expert in applied sociocultural medical anthropology and qualitative methodologies. Dr. Sobo specializes in HIV/AIDS, quality improvement, and organizational culture, and has extensive real-world experience in applying anthropological theory and methods (e.g., ethnographic and participatory action research methods) to health care delivery problems. Our work with Dr. Sobo will be augmented through the additional academic collaboration for Dr.Gregory Aarons, an organization psychologist.

OBJECTIVE(S):
Increasing HIV testing is a necessary step toward control of the disease.
Many experts suggest routinely offering HIV testing to specific population segments. We explore provider discourse regarding a HIV test implementation project with the aim of illuminating a structurally-emergent workforce-based strategy for promoting testing and the socio-cultural factors underlying it. The collaboration's long term goal is to strengthen scientific coherence, relevance, and clinical effectiveness of VA HIV implementation research and to enhance dissemination and sustainability of quality innovation. The immediate goal of the collaboration is to develop a practical organizational model for understanding various approaches toward disseminating and promoting QI initiatives within the VA.

METHODS:
Twenty US Veterans Affairs Healthcare System providers were interviewed. Using standard anthropological text analysis techniques, themes, their relationships, and the significance of these for increasing appropriately-targeted HIV test offers were established. Presenting the HIV test offer to their patients as if routine (routinization) supported providers' desire to do no harm by lessening the test's potential stigma.

FINDINGS/RESULTS:
Offering the test helped providers maintain professional integrity: it empowered veterans to realize access to care and fit with providers' sense of honor and duty. Routinizing HIV testing also helped providers to manage scarce time effectively. Findings can be leveraged to support routine screening's successful roll-out. The carefully managed introduction of routine HIV test offering policies will formalize and legitimize productive strategies of destigmatization already being enacted by some front-line providers. That routinization strategies are in use although HIV testing is not yet actually routine attests to the potential power routinization has to reduce HIV's stigma, increase HIV test uptake, and thereby improve access to care.

IMPACT:
The potential contributions of anthropology to VA management have been largely untapped. This academic expert collaboration supplement will apply the methods of social and organizational anthropology to problems in implementing and disseminating VA health care quality improvements and will help QUERI-HIV to greatly improve capacity for late-stage roll-out of implementation projects within the VA. As a result, measurable improvements in health outcomes for veterans with HIV are anticipated.

PUBLICATIONS:

Journal Articles

  1. Sobo EJ, Bowman C, Gifford AL. Behind the scenes in health care improvement: the complex structures and emergent strategies of Implementation Science. Social science & medicine (1982). 2008 Nov 1; 67(10):1530-40.


DRA: Health Systems
DRE: none
Keywords: HIV/AIDS, Implementation, Infectious disease
MeSH Terms: none

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