Assessing implementation and health equity determinants to develop a facilitation plan for varied intensity posttraumatic stress disorder (PTSD) treatments in minority serving institutions

Abstract

Though implementation science (IS) frameworks have recently been adapted to understand determinants of health equity (Woodward, et al., 2021), application of these frameworks in safety net hospital settings are new. We applied the Health Equity Implementation Framework to (a) understand determinants of implementation and equity and (b) develop an institution-wide implementation facilitation plan for three evidence-based practices (EBPs) for posttraumatic stress disorder (PTSD). We utilized researcher field notes from clinical case consultation gathered during PTSD treatment implementation initiatives (CPT, WET, Brief and web-administered STAIR) at the same safety net hospital (N=94 meetings total, from 2020–2023) to assess determinants of implementation and equity. We developed a qualitative codebook based on the Health Equity Implementation Framework to specify determinants and then build an implementation facilitation toolkit for multi-EBP implementation. Similar determinants were found across clinics and EBPs (e.g., provider training gaps and misperceptions about manualized treatments; inefficiencies in identification, triage, and referral pathways; patient engagement barriers related to stigma, literacy, and mistrust) with additional nuance per clinic and EBP. Institution-wide facilitation strategies were then utilized to enhance implementation and equity, and focused on enhancing both access and quality of services (e.g., training and consultation, refining referral pathways) and patient engagement (e.g., culturally responsive training, consultation, and treatment delivery). IS has an important role to play in enhancing health equity. Our findings illustrate how pooling determinants across clinics and treatments can help implementation scientists engage with hospital leadership and advocate for system-level implementation facilitation strategies.

Introduction

Implementation science (IS) aims to promote the translation of evidence-based practices (EBPs) from research to real-world settings with the goal of improving the quality and effectiveness of health services (Bauer et al., 2015; Eccles & Mittman 2006). Implementation scientists have made substantial progress in closing the research-to-practice-gap by identifying multi-level barriers and facilitators that affect the uptake and sustainability of EBPs in usual care, and tailoring implementation strategies to fit the needs of individual contexts (Brownson, 2018; Stetler et al., 2008). Marginalized populations face the largest treatment gaps because of historical exclusion from trials that informed the development and implementation of EBPs (Baumann & Cabassa, 2020; Santiago & Miranda, 2014; Yapa & Bärnighausen, 2018). Although over 100 implementation models exist as tools to guide implementation research, few include an explicit focus on health equity (Brownson et al., 2021). Only recently have health equity considerations been embedded in implementation models. That said, given the overarching goal of implementation science in closing research-practice gaps, implementation scientists are well-positioned to advance health equity. To do so, implementation scientists will need to expand determinant, process, and evaluation frameworks to include cultural and contextual factors, as well as examination of structural inequities that exist in healthcare settings (Baumann & Cabassa, 2020; Brownson et al., 2021; Chinman et al., 2017; Kerkhoff et al., 2022; Woodward et al., 2019).

One promising integrated implementation framework is the Health Equity Implementation Framework (HEIF), which expanded the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) determinants framework to include health equity concepts (Woodward et al., 2019). The original i-PARIHS, developed for healthcare settings, proposes that implementation success is determined by characteristics of the 1) innovation, 2) recipients (patients and providers), and 3) context (Harvey & Kitson, 2016). According to i-PARIHS, innovation determinants may include factors such as relative advantage, degree of fit, and trialability. Recipient determinants may include patient goals, values, or motivation as well as provider knowledge, skill, or the availability of local opinion leaders to champion the innovation. Finally, context determinants may include clinic/organization culture, leadership support, or healthcare system policies and priorities. i-PARIHS is user friendly for both practitioners and researchers and is more specific to healthcare settings than other frameworks (Woodward et al., 2019). The HEIF expanded i-PARIHS to include attention to interactional factors that occur within the clinical encounter (i.e., determinants that pertain to interactions between patients and providers during delivery of the innovation), culturally relevant factors of recipients including patients, providers, and others (e.g., caregivers), and societal context factors (Woodward et al., 2019, 2021). These factors are central to tailoring innovations and implementation plans to settings that serve marginalized patients. HEIF specifically names health literacy, medical mistrust, and provider attitudes and biases as pertinent culturally relevant factors. These culturally relevant factors influence the clinical encounter between patients and providers (e.g., whether an EBP is offered by providers and whether the EBP is accepted by patients). The HEIF authors also include broader contextual factors, such as economic and sociopolitical forces that drive inequities. Thus, HEIF includes important (perhaps unique) factors that influence successful and equitable implementation EBPs in settings that serve marginalized patients. Further, the HEIF’s aim to promote access to care (i.e., identification of disparities) and quality of care (i.e., disparate decisions made in the clinical encounter) make the framework a good fit for our setting.

Implementation facilitation (IF) is an evidence-based multifaceted process to support the implementation of EBPs and is the “active” ingredient in i-PARIHS (Baskerville et al., 2012; Harvey & Kitson, 2016; Kirchner et al., 2014; Ritchie et al., 2017; Ritchie, Parker, et al., 2020). At its core, IF recognizes that local factors are salient in determining the uptake and sustainability of innovations in real-world settings (Kitson et al., 1998; Rycroft-Malone et al., 2002), and provides a participatory process in which these factors may be targeted to improve implementation. The strengths of IF in the healthcare setting include the ability of these collective strategies to bridge communities and healthcare settings through a focus on clinical skill education, building trust, and addressing local context barriers, all of which are key to increasing health equity (Ritchie, Parker, et al., 2020). Multiple IF models may be used to support implementation, including external facilitation, internal facilitation, or both. More specifically, external facilitation relies on facilitators outside of the organization (e.g., individuals with general expertise in implementation or the innovation), whereas internal facilitation includes facilitators embedded within the local organization who provide direct implementation support to a clinic or practice in which they are embedded (Ritchie, Dollar, et al., 2020). In all models, internal and external facilitators enlist other change agents (i.e., local site champions, an implementation team) to assist in achieving successful implementation (Ritchie, Kirchner, et al., 2020). Models that incorporate internal facilitation are crucial for health equity work, as this process facilitates trust building with key partners as local facilitators can build and sustain collaborations with local experts. Formative work in our setting focused on building researcher-practitioner collaborations and identified trust as barriers to implementation (Valentine et al., 2023a, which is well-aligned with the participatory nature of IF.

In their scoping review, Smith and colleagues characterize IF as a multifaceted process that includes interactive problem solving to support stakeholders in adopting the innovation in routine practice (Smith et al., 2024). The IF process is an ongoing and collaborative partnership with local stakeholders to continuously evaluate and adapt innovation efforts to make research-based strategies practically supportable (Dogherty et al., 2013; Harvey & Kitson, 2016). The participatory nature of IF is especially well-suited for health equity research, as it centers the importance of trust and shared decision-making. Some implementation strategies within IF overlap with other frameworks such as the Expert Recommendations for Implementing Change (ERIC; Powell et al. 2015). For example, IF and ERIC both include strategies to involve local key players and change agents, and to identify and prepare champions. However, IF comprises 32 distinct activities that are particularly applicable to our projects, including adapting the program to the local context without compromising fidelity, providing clinical skill education, and fostering structural organizational change (Smith et al., 2024).

Equity-focused implementation determinants models and IF activities are needed to support the development of tailored strategies for addressing racial and economic inequities in posttraumatic stress disorder (PTSD) treatment access and quality. Despite higher rates of trauma exposure (interpersonal violence rates up to 94%; Gillespie et al., 2009) and PTSD diagnosis (up to 50% higher than the general population; Gluck et al., 2021) among low income and racially marginalized communities, PTSD treatment remains largely inaccessible. That is, only 13% of individuals with PTSD receive any mental health treatment (Alim et al., 2006). Established causes of disparities in PTSD care in low-resource settings easily map onto i-PARIHS domains. For example, in the Context domain, determinants include fewer mental health specialists and limited access to EBP training (Blanco et al., 2007; Cook et al., 2014; Garland et al., 2005; Le Cook et al., 2013). In the Recipient domain, determinants include medical mistrust due to historical and ongoing discrimination in healthcare, low mental health literacy, and stigma (Ghafoori et al., 2014; LaVeist et al., 2009; Valentine et al., 2016). In the innovation domain, determinants include the high time and cost burden of providing established EBPs for PTSD (e.g., those with long duration and high clinical intensity; direct reprocessing of trauma memory) and perceived poor fit of EBPs for “complex patients” or within local care settings.

A better understanding of IF strategies may support successful adaptation, uptake, and sustainability of EBPs for PTSD across clinics in a safety net hospital setting, which provide health care to uninsured or Medicaid-insured (Lewin & Altman, 2000), and serve predominately low income and racially marginalized patients. Further, developing a continuum of care options that balance demonstrated efficacy and effectiveness, fit with delivery setting, and patient preferences presents an opportunity to increase access to and quality of care for marginalized patients by tailoring intervention selection and implementation to the local context. While there is literature on implementation determinants of Cognitive Processing Therapy (CPT; Marques et al., 2016), Written Exposure Therapy (WET; Valentine et al., 2023b), and Brief Skills Training in Affective and Interpersonal Regulation (STAIR; Godfrey et al., 2023; Smith et al., 2020) in these types of settings, what remains unknown, is how IF activities can promote broad EBP implementation in resource-constricted health settings. In this study, we aim to apply IF strategies to address cross-clinic access and quality gaps in the safety net hospital setting.

In sum, although people from marginalized populations can equally benefit from first-line PTSD treatments, there is also research to suggest they may have worse outcomes in symptom reduction (Sripada et al., 2017) and lower retention rates (Lester et al., 2010). These disparities are often the result of interlocking and multi-level inequities such as systemic discrimination or provider bias (Brownson et al., 2021). Disparities in treatment accessibility, engagement, and outcomes underscore the need for IF to address the unique needs of organizations serving marginalized people, such as safety net hospitals. In this study, we present our use of the HEIF to (a) understand determinants of implementation and equity for EBPs for PTSD provided at a large safety net hospital, and (b) develop an institution-wide implementation facilitation plan for three PTSD treatments: CPT, WET, and Brief and web-administered STAIR.

Method

Local Setting

Boston Medical Center Health System (BMC).

This study took place in the largest safety net hospital in New England, where most patients identify with a racially or ethnically marginalized group (82%) and are insured by Medicaid (70%). Demand for behavioral health services is high with over 500 referrals for behavioral health each month in general outpatient psychiatry and integrated behavioral health (Godfrey et al., 2023). The Recovery from Stress and Trauma through Outpatient care, Research, and Education (RESTORE) Center at BMC provided implementation facilitation at the hospital system level. Our exemplar projects occurred within the following clinical settings at BMC: integrated behavioral health, obstetrics, and outpatient psychiatry. These project settings are described below.

Integrated Behavioral Health (IBH).

Therapists in IBH have 50% of their clinical time reserved for 30-min scheduled visits, with remaining time left unscheduled for warm handoffs. In the local setting, given the large patient volume relative to clinical staff, therapist burden is high, and providers are typically only able to accommodate scheduled sessions every 4–6 weeks. Therapists were 10 embedded clinical social workers and two embedded clinical psychologists in IBH. Therapists who delivered Brief STAIR attended a 4-hour didactic training led by (senior author) a nationally certified trainer in Brief STAIR, biweekly group consultation, and received individual written feedback based on audio review of two training cases. For full description of the project, see Valentine et al., 2023a.

Obstetrics (OB).

In OB, clinical social workers are responsible for case management, crisis response, and brief support, yet therapy provision is not typically central to their role given the complexity of competing patient needs. Therapists were three embedded clinical social workers in OB and one trainee in a mental health counseling Master’s program. Therapists completed a 5-hour training in WET by the intervention co-developer, a 2-hour training on study-specific procedures, and received weekly consultation and individual written feedback based on audio review of sessions.

Outpatient Psychiatry (OP).

Clinical social workers and psychologists in OP have most of their clinical time reserved for scheduled 60-minute visits and biweekly blocks for new patient intakes. In the local setting, the demand is high relative to staffing and provider availability resulting in a high therapist burden. Therapists included embedded clinical social workers and psychologists. This project was not a formal research study, as such, consultation attendees rotated throughout the project. On average 10 therapists were present at each session. Therapists attended a 2-day training led by a nationally certified CPT trainer and engaged in biweekly group consultation.

Internal Facilitation and Local Champions

Facilitation is the process in which implementation barriers in each domain (i.e., innovation, context, and recipients) are addressed. Facilitators may be internal or external to the local setting and are experts in implementation of selected innovations and possess a diverse range of skills to effectively facilitate change in the setting. IF models vary depending on the role of facilitators (i.e., external, internal, or both). External facilitation is often used in settings where local staff lack expertise and skills needed for implementation (Ritchie, Dollar, et al., 2020). For this project, we used an internal facilitation model, in which the facilitator works with local champions and a broader implementation team (Ritchie et al., 2017). The PI (last author) served as internal facilitator, given her dual expertise in the selected EBPs and in implementation science. Although there were no external facilitators, the PI was mentored by lead implementation scientists and intervention developers throughout the described projects. Authors three and four served as local champions (IBH and OP, respectively) and were key to employing IF strategies such as action/implementation planning, adapting program to local context without compromising fidelity, clinical skills education, developing shared vision/consensus building, and fostering organizational changes in culture and structure (Smith et al., 2024).

Interventions

Brief STAIR is a five-session version of STAIR, a cognitive behavioral therapy for PTSD (Cloitre et al., 2002), designed for delivery in primary care (Jain et al., 2020). Brief STAIR focuses on psychoeducation and coping skills training, and does not require recount of the trauma memory. In randomized controlled trials, Brief STAIR reduced PTSD symptoms (Cloitre et al. 2023). For a full description of Brief STAIR, see Jain et al., 2020.

WET is an exposure-based treatment for PTSD with strong demonstrated efficacy (LoSavio et al., 2023) and is included on the list of expert-recommended PTSD treatments. WET consists of five or six sessions that include PTSD psychoeducation, writing about a specific trauma experience, and a brief check-in with the writing process (Sloan & Marx, 2019; Sloan et al., 2012; Sloan et al., 2013). For a full description of WET, see Sloan et al., 2012.

CPT is a gold-standard PTSD treatment. CPT aims to identify and address cognitive distortions that are hypothesized to maintain PTSD symptoms. Treatment consists of 12 sessions focused on helping patients modify or challenge unhelpful trauma-related beliefs (Resick & Schnicke, 1992, Resick et al., 2017). For a full description of CPT, see Resick et al. 2002.

Scope of Included Implementation Projects

This study includes data from three PTSD EBP implementation initiatives in Boston Medical Center the same safety net hospital serving predominately Medicaid-insured, low income, and racially marginalized patients. The key components of each project are outlined in Table 1. Project 1 (IBH) is a NIMH-funded (NCT04937504) randomized control trial testing the delivery of two modalities (clinician-administered vs. web-administered) of Brief STAIR. Brief STAIR is a low-intensity PTSD treatment that was delivered in integrated primary care among adult primary care patients. Project 2 (OB) is an internally funded open trial testing delivery of WET, a brief, high-intensity PTSD treatment, among pregnant people with comorbid PTSD and substance use disorder (SUD) receiving care in an integrated obstetrics-addiction clinic. Project 3 (OP) consisted of a training-only initiative (not grant funded) and included delivery of CPT among patients in adult outpatient psychiatry as part of usual care with biweekly group consultation led by the principal investigator (PI).

Table 1.

Project Summaries

Title (dates)	Design	Training/Consultation	EBP(s)	Setting	Participants	Provider Type
IBH (2021 –2023)	Open Trial NIMH-funded (NCT04937504)	4-hour didactic training led by (senior author), biweekly group consultation with PI, individual audio review with feedback	Brief STAIR	Primary Care	Usual care patients with subthreshold or full PTSD based on PCL-5	IBH specialists (clinical social workers, psychologists, psychology trainees)
OB (2019 – 2021)	Open Trial Internal Funding	5-hour training with the co-developer; a 2-hour study-specific training; weekly consultation with PIs; individual audio review with feedback	WET	Obstetrics	Pregnant people with substance use histories who have subthreshold or full PTSD based on the PCL-5	Social workers and other master’s level clinicians
OP (2020 – 2023)	N/A Training Only Unfunded	2-day live webinar training led by a nationally certified CPT trainer; biweekly group consultation with PI	CPT	Outpatient Psychiatry	Usual care patients with full PTSD based on the PCL-5 > 33 or clinical judgement	Social workers and other master’s level clinicians, psychologists

Note: IBH = integrated behavioral health, OB = obstetrics, OP= outpatient psychiatry, CPT = cognitive processing therapy, IBH = integrated behavioral health, PI = principal investigator, PTSD = posttraumatic stress disorder, PCL-5 = PTSD Checklist for the DSM-5, STAIR = skills training in affective and interpersonal regulation, WET = written exposure therapy

Method

We conducted an ethnographic qualitative study to 1) characterize implementation and equity determinants and 2) identify IF activities to address these determinants across three implementation initiatives for EBPs for PTSD within the same safety net hospital. Analysis was guided by the HEIF, an extension of the i-PARIHS implementation framework, which defines determinants under three broad multi-level domains: Innovation, Context (inner and outer level factors such as resources, specific clinic characteristics, broader organization), and Recipients (individuals who influence implementation [providers], and those affected by implementation [patients]). HEIF integrates three new domains into i-PARIHS including culturally relevant factors of recipients (bias, attitudes), clinical encounter (patient-provider interaction), and societal context (sociopolitical forces, social determinants of health).

Data Collection

Consistent with ethnographic methods, this project relied on qualitative analysis of consultation field notes collected in real-time from the three implementation projects. Consultation field notes were collected for each project by a research assistant (RA; trained by senior author) who was instructed to focus on capturing implementation determinants. The content of field notes was consistent across interventions and included documentation of real-time implementation barriers (i.e., determinants identified early in the projects) as well as general notes on case conceptualization and patient characteristics. No identifiable patient information was included in field notes. The same data collection method was used in each project. Data were integrated, the process of bringing data sets together, in this case across three sets of field notes at the point of analysis (Cronin et al., 2008). Field notes were synthesized from three data sources (i.e., clinical consultation meetings). In IBH, therapists engaged in 25 consultation meetings from June 2021 – March 2023. In OB, therapists engaged in 47 consultation meetings from October 2019–June 2021. In OP, therapists engaged in 22 consultation meetings from May 2021 – March 2023.

Analysis

A team-based approach was used to analyze consultation field note data. The coding team consisted of one doctoral-level clinical psychologist, one postdoctoral fellow, one post-baccalaureate RA, and one undergraduate RA. To integrate data sets, first, each source was analyzed independently resulting in emergent findings (Cronin et al., 2008). In this first step, coding was divided across three team members (i.e., one set of field notes per coder), who independently coded the field notes from separate projects to identify salient emergent themes pertaining to implementation determinants in each setting.

Next, a directed content analysis approach (Hsieh & Shannon, 2005) was used to analyze determinants. In this approach, data were linked to predetermined categories (Assarroudi et al., 2018) within the HEIF (e.g., recipients, innovation, and context). An a priori codebook was developed from the HEIF. The coding team reviewed emergent themes and coded them based on the HEIF determinants domains. The team met weekly to review application of codes. Individual team members highlighted text that appeared related to the HEIF domains and then the full team further analyzed the highlighted text to reach a consensus (Assarroudi et al., 2018). In the final step, emergent findings and codes derived from the HEIF were juxtaposed to create a codebook used to analyze all three data sources. The coding team identified crosscutting findings (See Table 2) and findings that were unique to each implementation project (Supplemental Table 1). Implementation facilitation strategies were then operationalized for reach determinant to respond to implementation barriers across settings (Table 2).

Table 2.

Summary of Key Implementation Determinants and Facilitation Strategies

Cross-Cutting Health Equity Implementation Determinants		Implementation Facilitation Strategies
Recipients: Provider *Culturally Relevant Factors	Provider practice and attitude shifts New to manualized treatments New to directive style of EBPs Time burden to prepare for sessions Challenges terminating patients who responded well to EBPs Misperceptions that trauma-focused treatments may be harmful for complex patients* Biases around trauma exposure in the absence of universal screening*	Engage providers as key partners (IBH, OB, OP) Identification/selection of local change agents (IBH, OB, OP) Promoting cultural change required for implementation (e.g., overcoming resistance to change) (OP) Data collection to assess context and baseline performance (IBH, OB) Describe/clarify clinician responsibilities and roles, formalize roles of implementation team, and extend to community health workers (Phase 3)
	Provider novice skills in assessment and case conceptualization* Challenges with case conceptualization for PTSD (e.g., integration of social stress into treatment approach, differentiating PTSD from bereavement)* New to measurement-based care Low perceived self-efficacy around assessing/asking about trauma	Clinical skills education (IBH, OB, OP) Providing support, being helpful, consultation group, clinician-researcher partnership, and available (IBH, OB, OP)
	Provider self-efficacy Provider comfort with fidelity-consistent modifications	Clinical skills education (IBH, OB, OP)
Recipients: Patient *Culturally Relevant Factors	Patient engagement* Competing priorities (other behavioral health needs, ongoing stressors) may interfere with treatment* Ambivalence about engaging in trauma-focused treatment Gender disparities: challenges engaging men* PTSD avoidance may result in treatment interfering behavior Buy-in (treatment expectancies) Greater stigma and mistrust among patients with marginalized identities*	Engage patients as key partners (IBH, OB)
	Patient PTSD/emotion literacy Understanding treatment rationale Difficulty labeling emotions Unfamiliar with PTSD diagnosis and symptoms Low mental health literacy*	Engage patients as key partners (IBH, OB) Technical support: creating patient psychoeducational materials and information handouts
	Social determinants of health Transportation barriers* Childcare barriers* Access to technology*	Administrative tasks: contacting patients to complete measures, scheduling visits (IBH, OB, OP) Connecting to resources (case management and social work)
Context *Societal Context	Workforce capacity Challenges accommodating biweekly frequency (standard for EBPs) High provider turnover Challenges completing patient outreach due to limited staff Few bilingual providers	Administrative tasks: contacting patients to complete measures, scheduling visits (IBH, OB, OP) Providing updates and feedback on implementation processes Building a business case for implementation facilitation
	Outer setting Low-resource settings have limited training and consultation for EBP* Limited time for session preparation, admin, documentation tasks Institutional and state support for EBP adoption High no-show rate (“underutilization”) Gaps in standard operating procedures, especially for telehealth delivery (e.g., safety assessment, privacy concerns) Increased attention and support around considerations of racism-based stress*	Action/implementation planning (IBH, OB) Managing group/team processes with reciprocal and participatory methods (IBH, OB) Promoting structural change required for implementation (e.g., methods for referring patients, how patients navigate through the healthcare system) Helping to hire clinical program staff (add community health workers to team) Secured dedicated clinical FTE for therapists to provide trauma-focused therapy in RESTORE Conduct ongoing monitoring of program implementation Developing shared vision/consensus building Goal/priority setting for the hospital system Marketing
	Social determinants of health Neighborhood segregated transportation access* Cost of childcare* Access to technology* Added complexity and time burden of providing EBPs with an interpreter	Promoting structural change required for implementation (e.g., trauma-informed training for non-clinical staff, protected clinician time) Administrative (translating documents into Spanish)
Characteristics of Innovation *Clinical Encounters	Cross-cutting characteristics of three EBPs (Brief STAIR, WET, CPT) Standard frequency and duration of treatment is incompatible with context (e.g., 30–45 min sessions, bi-weekly visits) Poor guidance from EBPs on how to integrate social context into PTSD case conceptualization and treatment (e.g., e.g., Identifying adaptive responses to discrimination, not over-pathologizing, validating cognitions rooted in actual threat)* Lack of language accessibility for cultural adaptations* Need for shared decision-making to select best treatment option for patient* Need for enhanced orienting patients to trauma-focused treatments (e.g., educating patients on misperceptions of harm/contraindicators; discussion of expected symptom trajectory) Need for enhancements to PTSD psychoeducation (e.g., treatment models, therapy rationale)*	Adapting program to local context without compromising fidelity (IBH, OB) Fostering networking with external experts Technical support: creating patient psychoeducational materials and information handouts

Note. CPT = cognitive processing therapy, EBP = evidence-based practice, PTSD = posttraumatic stress disorder, STAIR = skills training in affective and interpersonal regulation, WET = written exposure therapy

Findings

Our evaluation of implementation determinants was guided by the HEIF (Woodward et al., 2019, 2021). We used consultation field notes (N = 94; total word count reviewed = 52,847) to assess determinants of implementation (i.e., recipients, context, innovation) and health equity (i.e., culturally relevant factors, clinical encounter, societal context). We present key findings by HEIF determinant domains (Table 2), starting with general determinants across projects followed by health equity specific determinants. Our findings yielded mostly barriers to implementation with less attention on facilitators, as we sought to first characterize determinants, which would then inform future IF strategies. See Supplemental Table 1 for a comprehensive list of determinants identified in each project.

Recipients: Providers

General Determinants: Providers

Across projects, implementation barriers for provider-recipients centered on shifts in practice, novice skillsets, and self-efficacy. First, providers described how unfamiliarity with manualized EBPs resulted in difficulties adhering to the structure of the intervention. Next, providers reported being new to the directive style of manualized treatments. They described a need to build skills and self-efficacy with EBPs, especially when patients presented with competing social needs and clinical priorities. Providers were also new to measurement-based care that is typically implemented alongside EBPs. For example, providers were new to using instruments such as the PTSD Checklist for DSM-5 (PCL-5; Weathers, Litz et al., 2013) and Life Events Checklist for DSM-5 (LEC-5; Weathers, Blake et al., 2013) in clinical encounters. Provider self-efficacy in these areas added to provider burden such as the time needed to prep for sessions (e.g., gathering materials, reviewing the manual, and translating knowledge to practice). As providers’ self-efficacy increased, their confidence in making fidelity consistent modifications to support EBP fit with setting and patients’ needs also increased. Providers also shared their overall struggles with treatment termination, even when clinically indicated. Additional unique provider determinants were identified for each project (Supplemental Table 1). For instance, Brief STAIR has less instruction to guide the conceptualization of patients’ symptoms. A unique determinant for CPT included that providers had biases regarding who could benefit from the treatment (e.g., the misperception that CPT was better for patients with a higher level of education). Finally, WET providers expressed more challenges with managing their own affective responses to exposure therapy techniques.

Determinants Specific to Health Equity: Providers

The HEIF frames the clinical encounter, where clinical decisions are made, care is received, and patients and providers interact, as important to health equity due to the many behavioral and perceptual factors that affect the encounter. Factors like bias and power differentials affect clinical decisions such as conceptualization of trauma and deciding when or which trauma(s) to process. The patient population in our setting has a high rate of trauma exposure and low access to EBPs for PTSD. Deciding when to process new traumas, as they were frequently disclosed, is at the intersection of health equity determents such as higher trauma exposure associated with marginalization, low access to care, and potential bias in decision making. Further, without universal screening for PTSD or utilization of measurement-based care, clinicians ultimately decide who to offer PTSD treatment to, which leaves room for implicit bias. Additionally, providers described challenges unique to the patient population that affected engagement and warranted treatment adaptation. For example, chronic trauma exposure was common among patients, yet many patients did not recognize their experiences as trauma and were unfamiliar with PTSD. This contributed to treatment ambivalence and necessitated additional psychoeducation, normalization, and treatment orientation to facilitate buy-in. In consultation meetings, providers sought feedback on assisting patients with labeling their emotions, identifying symptoms of PTSD, and familiarizing themselves with PTSD diagnosis. Determinants impacting engagement and retention also emerged as major barriers in this domain. Providers expressed difficulty engaging patients in trauma-focused EBPs due to general themes of ambivalence about engaging in trauma-focused treatment and symptoms of avoidance interfering with treatment. Each project also has unique patient determinants. In Brief STAIR, patients had difficulty completing assignments between sessions. In CPT, patients had difficulty generalizing skills to other stuck points. In WET, patients had difficulty sticking to the same index event in subsequent writings. Further details about unique determinants per project can be found in Supplemental Table 1.

Determinants Specific to Health Equity: Patients

Regarding determinants linked to health equity, patients of racial and economically marginalized backgrounds expressed increased mental health stigma and mistrust of the healthcare system based on previous experiences of harm within the healthcare system. These factors led to reluctance to engage in treatment, though treatment delivery in non-specialty mental health settings (integrated primary care, OB) was successful in combating stigma. Additionally, social determinants of health, though originating from systemic inequities, presented challenges to treatment engagement within the clinical encounter. For example, competing behavioral health needs (e.g., housing, employment, non-trauma-related mental health concerns) led to frequent interruptions in treatment, and access to childcare, transportation, and technology for telehealth affected the ability to attend sessions. As such, provider determinants (e.g., comfort with fidelity consistent modification) and patient determinants (e.g., competing needs) informed IF strategies (e.g., clinical skill education) to support fidelity-consistent cultural tailoring of EBP implementation (Table 2 and Supplemental Table 2). IF thus supported uptake of EBPs which may have otherwise not been offered.

Context

General Determinants: Context

Context-level determinants across projects were often related to high provider burden and workforce capacity challenges in the institution (e.g., turnover, few bilingual providers). Small clinical staffing relative to large patient volume posed challenges in accommodating the frequency of sessions indicated standard in EBPs. For example, in IBH, providers are typically only able to accommodate regular sessions every 4–6 weeks, whereas Brief STAIR calls for biweekly sessions. In OB, therapy was supported by grant funding and is otherwise not considered central to the responsibilities of clinical social workers. As such, provider schedules fluctuate to accommodate immediate patient needs (crisis and case management), and prioritizing weekly WET sessions was a challenge. Although scheduling support was provided by study teams in Projects 1 and 2, the sustainability of biweekly sessions was a concern. Providers across settings described having little protected time in their schedules for training, consultation, patient outreach, and administrative tasks associated with preparation for EBP provision. As such, IF strategies (e.g., administrative tasks) were operationalized to address system and context barriers (Table 2 and Supplemental Table 2).

Determinants Specific to Health Equity: Context

In the societal context, systemic inequities faced by the safety net hospital and patients served were salient health equity determinants that impacted all other domains. For example, provider training gaps described earlier reflect disparate access to EBP training in low-resource settings rather than characteristics of providers themselves, who across all projects were eager and highly skillful in delivering EBPs. Similarly, many patients are of low socioeconomic status, and factors that interfered with patient treatment engagement (e.g., transportation, childcare, technology access) are a product of societal marginalization. Most patients served by the institution are from racial and ethnic marginalized populations, and experiences of racism and discrimination were often relevant to symptom severity and treatment needs. Thus, consultation meetings across projects often centered discussions of how skills in existing EBPs for PTSD can be applied to additionally cope with oppression-based stress.

Innovation Characteristics:

General Determinants: Innovation

Cross-cutting innovation determinants included the general fit of EBPs with the local setting and client needs. For example, providers expressed concerns that the standard frequency and duration of EBPs were not conducive to their existing workflows, where session time is often limited, and frequent sessions are not always feasible. The selection of interventions that are feasible in the local setting was an important consideration necessary for successful implementation. For example, 30-minute Brief STAIR sessions fit the existing IBH workflow, CPT was feasible in the outpatient psychiatry clinic where longer sessions and higher-intensity interventions are more typical, and WET was successful in OB as it is highly efficacious, and its brevity allowed it to be implemented alongside prenatal visits in the clinic. Similarly, given high no-show rates, providers described the need for greater flexibility in the number of sessions. Due to varied intensity of EBPs, there were also differences across projects. IBH providers found the low-intensity of Brief STAIR (i.e., does not require recount of trauma memory) to be helpful in combating patient ambivalence, and its transdiagnostic nature was good fit for a wide range of patients. In OB, the focus on a singular index trauma event in WET posed some initial challenges among patients with repeated and chronic trauma exposure, and its high intensity required increased rationale and setting treatment expectations to combat patient avoidance of the trauma (Supplemental Table 1).

Determinants Specific to Health Equity: Innovation

In addition to concerns around EBP structure, providers reported that EBPs lacked guidance on how to integrate social context into PTSD case conceptualization and treatment, which is necessary to promote equity and close the research-to-practice gap. Although providers affirmed that standardized EBP trainings were important in learning intervention components, they emphasized that culturally responsive case consultation was necessary in learning how interventions can be tailored to fit the needs of diverse clients. Additionally, lack of language accessibility of treatment manuals is a significant equity-related barrier. Over a third of patients in this hospital do not speak English as their first language, and the lack of bilingual providers as well as translated intervention materials often prevented providers from offering EBPs to clients that may benefit from them. Even when interpreter services are available challenges exist such as inability of providers to prepare interpreters for complex clinical encounters. Finally, clinicians noted a need to enhance EBPs with processes for shared decision making, orientation to PTSD, and psychoeducation on treatment rationale.

Three Phases of Implementation Facilitation

Coding occurred simultaneously with preparation of the launch of the Recovery from Stress and Trauma through Outpatient care, Research, and Education (RESTORE) Center, which houses an implementation facilitation team that supports EBP implementation across BMC clinics. Thus, the goal of the current study was to identify implementation determinants across initiatives that directly informed the RESTORE Center’s strategic plan (IF activities) to promote uptake and sustainability of each intervention. This resulted in three phases of implementation facilitation. A summary of core IF activities (Smith et al., 2024) selected to directly address implementation determinants is presented in Table 2. See Supplemental Table 2 for a comprehensive list of IF strategies in each phase based on Smith and colleagues review and definitions of core IF activities (Smith et al., 2024). Of note, IF activities are continued into the following phases, thus are not repeated in the table for readability.

Phase One Goal: Clinician Buy-in

The first phase of implementation facilitation was completed across three projects from 2020–2023. Findings are supported by consultation field notes. In this phase, we focused on addressing innovation and recipient determinants (i.e., clinical encounter). This included increasing clinician buy-in for EBPs through activities such as action planning which consisted of prioritizing access to training and consultation for clinicians and embedding EBPs in routine care. Details on activities for each IF strategy are included in Supplemental Table 2.

Phase Two Goal: Department Leadership Buy-in

The second phase of implementation facilitation consists of the RESTORE Center centralizing, standardizing, and scaling up the infrastructure needed to support the implantation of EBPs for PTSD across the hospital system. The implementation facilitation team is active in this phase. Findings from consultation field notes were used to operationalize the RESTORE Center Strategic Plan. The operationalized IF strategies were reviewed by local change agents who provided additional feedback and recommendations. The focus of phase two is to increase the buy-in from the department to support both dissemination of EBPs and implementation facilitation through strategies such as developing a shared vision. This includes collaborating with advisory boards (i.e., hospital leadership, clinicians, and patients), research-clinician partnerships to create shared goals, and developing a strategic plan aligned with department and hospital goals. A list of all activities for each IF strategy are included in Supplemental Table 2.

Phase Three: Hospital System Leadership Buy-in

The final phase of implementation facilitation is to expand the reach of EBPs for PTSD across the hospital system. The central goal is to obtain buy-in from the hospital to support the ongoing refinement of the IF strategies and to make a business case for financial support of the RESTORE Center (IF). In this phase, the focus will shift to address context level determinants that drive inequities (i.e., social determinants of health) of which outcomes were previously addressed at recipient level determinants (e.g., clinical encounter). This phase has not yet started. Findings are supported by the identified determinants which resulted in a strategic plan reviewed by key informants.

Discussion

The current study applied the Health Equity Implementation Framework (HEIF) to 1) characterize multi-level determinants of implementation and equity across three PTSD treatment initiatives within the same safety net hospital, and 2) develop an implementation facilitation plan to promote institution-wide dissemination. This is the first study, that we know of, to apply the HEIF within the context of a safety net hospital serving mostly Medicaid-insured, low income, and racially marginalized patients. Determinants of implementation and equity were similar across projects (e.g., workforce capacity limitations, lack of protected time for training and consultation, patient engagement barriers related to stigma, literacy, and mistrust, and fit of intervention components with the local context). Additionally, our novel cross-comparison of EBPs varying in intensity, brevity, and delivery setting elucidates idiographic intervention-specific barriers and facilitators to implementation, which can inform how intervention selection and treatment provision may be tailored to best meet local setting needs. Institution-wide facilitation strategies were then used to enhance implementation and equity and focused on enhancing both access and quality of services (e.g., training and consultation, refining referral pathways) and patient engagement (e.g., culturally responsive training, consultation, and treatment delivery). This study demonstrates how implementation science models can be applied to address both implementation and equity determinants.

Our study applies an equity-focused framework to elucidate both implementation and equity determinants. Though our project was specific to PTSD treatment initiatives in a safety-net setting, cross-cutting innovation barriers resemble challenges that are pervasive across evidence-based psychotherapies generally and commonly cited in the implementation literature. These include provider lack of access to and time for training (Cook et al., 2009), poor intervention compatibility with the local (Damschroder et al., 2009), and perceived treatment inflexibility/lack of guidance on tailoring EBPs to individual client needs (Gallow & Barlow, 2012). Determinants were also consistent with other PTSD treatment implementation initiatives, including workforce capacity limitations, time burden of EBPs, provider self-efficacy, and patient stigma in seeking mental health services (Ackland et al., 2023; Foa et al., 2013; Yamokoski et al., 2023). However, this research is limited to Veterans Health Administration (VHA) settings (Ackland et al., 2023; Yamokoski et al., 2023). Our findings extend the literature by identifying determinants in a non-VHA safety net hospital, which has important implications for advancing health equity. For example, dissemination of EBTs for PTSD has been a higher priority in VHA settings. Thus, health system leadership buy-in is already established, and greater resources are allocated to support implementation, including widespread access to training in EBTs (Karlin et al., 2010). As such, provider lack of training in EBTs is less commonly a barrier to implementation in VHA settings, whereas providers in the present study reported being new to manualized treatments. Notably, Yamokoski and colleagues (2023) used the i-PARIHS framework to identify implementation determinants and facilitation activities associated with implementation of massed delivery of EBPs for PTSD in three VHA care centers. Determinants that paralleled our findings include the need for protected provider time or administrative assistance for scheduling and sending patient materials, intervention fit with the existing workflow, and feasibility advantages of time-limited interventions (Yamokoski et al., 2023). By using the HEIF (an adaptation of i-PARIHS), we extend this work by highlighting equity-related domains, including culturally relevant factors (e.g., stigma, mistrust due to historical maltreatment in health care settings), societal context (e.g., limited provider access to EBP trainings in low-resource settings), and clinical encounter (e.g., need to tailor interventions to consider oppression-based stress). Attention to these equity-related factors is an important advancement in the literature, as it can then inform strategies to improve access and quality of EBPs to ameliorate stark racial and socioeconomic disparities in PTSD.

Facilitation is widely recognized as a necessary component of successful implementation (Dollar, n.d.; Harvey & Kitson, 2016), yet facilitation strategies remain poorly defined, and there is a lack of guidance on how they may be operationalized (Smith et al., 2024). Additionally, evaluation of strategies used to address implementation determinants and promote uptake of EBPs for PTSD have largely been concentrated in VHA settings (Ackland et al., 2023; Yamokoski et al., 2023), and there is a dearth of literature on implementation facilitation plans to address the unique barriers faced by low-resource settings such as safety net hospitals. For example, although wide dissemination of training in EBPs and protected time for ongoing training and consultation has yielded successful implementation outcomes in VHA settings (Ackland et al., 2023; Foa et al., 2020), these strategies are particularly challenging and may not be immediately feasible in low-resource settings. Notably, Ackland et al. (2023), conducted a systematic review of EBT for PTSD implementation and found the only implementation facilitation activities described in non-VHA settings were provider training initiatives, compared to a range of implementation strategies employed in VHA settings (e.g., provider training (Karlin et al., 2020), patient psychoeducation groups (Dedert et al., 2020), and external facilitation (Sayer et al., 2021). Our findings fill these gaps by illustrating how IF activities may be selected and tailored to address determinants of equity and implementation in a safety net hospital. Our facilitation plan sorted IF activities into three phases: clinician buy-in (e.g., prioritizing access to training and consultation for clinicians and embedding EBPs in routine care), department leadership buy-in (e.g., developing shared vision and consensus building and promoting structural change to support scaled-up implementation of EBPs across the BMC clinics), and hospital system leadership buy-in (e.g. ongoing monitoring of program implementation, providing updates and feedback on implementation processes, building a business case for local implementation facilitation). This plan for institution-wide dissemination provides a blueprint for institutions serving people of color to successfully implement EBPs.

Implications

Our findings indicate that addressing determinants associated with trust across recipient domains (e.g., patients, providers, community) was crucial for the implementation of PTSD treatment initiatives across clinics within the same safety net hospital and is an important strategy for achieving health equity. For provider recipients, HEIF-specific determinants associated with trust may have included limited access to EBP training. For example, limited access to training and resources for implementation may reinforce clinicians’ mistrust of EBPs for PTSD which is based on the historical exploitation of vulnerable groups by researchers and the medical system (LaVeist et al., 2009; Ghafoori et al., 2014; Valentine et al., 2016). As such, phase one of the IF strategies focused on increasing clinician buy-in to use EBPs. These IF strategies included finding local change agents, engaging clinicians as key partners, and shifting culture through shared mission as well as providing support for implementation barriers. Truly effective research-practice partnerships are built on mutual trust and collaboration. In our study, we were able to foster strong collaborative relationships and build trust with partners through a deep understanding of the local institutional, patient, and clinical context as well as clinical expertise on the team. Strategies to address health inequities are a local issue as clinical and setting-level factors are salient determinants to patients and providers (Hilgeman, 2023). However, most researchers engaged in IF work are external to the institution and/or not a clinician (Ritchie, Parker et al., 2020). Thus, institutions should invest in local clinical implementation scientists and internal implementation facilitation models to improve health equity.

Health equity implementation science is focused on building research-practice trust across the patient, provider, and system levels. Implementation scientists’ role and the IF strategies they employ should therefore focus on building trust which is particularly relevant to institutions serving people of color, given that patients experience historical and ongoing oppression that is naturally associated with mistrust and stigma of hospital care. The resources and organization costs associated with supporting the implementation of EBPs are substantial in settings with a large number of contextual barriers and stakeholders required for change. Minority-serving hospitals likely will benefit from local implementation facilitators as their settings are ripe with structural and organizational barriers (e.g., staff turnover, low resources) and involve numerous stakeholders. Therefore, to sustain gains in PTSD care health equity (e.g., access to care, quality of care) it may be necessary for these institutions to embed implementation scientists in the local workforce.

Finally, our findings highlight the importance of the clinic encounter. There is need to tailor EBPs for PTSD to address oppression-based stress and subsequently build trust with marginalized communities. Our local clinicians, a majority of which were social workers, were particularly savvy at culturally responsive care. The training model of social work programs particularly emphasizes a systems perspective in care. Further, the anti-oppressive movement is rooted in social work theory and aims to address social inequalities in clinical work, address the power imbalance between patient-provider and/or patient-health system, as well as create systemic changes to service delivery (Clifford & Burke, 2005; Strier & Binyamin, 2014). Thus, institutions serving people of color should invest in multicultural, social justice, and anti-oppressive training for providers with particular attention to building provider self-awareness, systems knowledge, and skills to support culturally responsive care in clinical encounters.

Limitations

This study has several limitations that may affect the generalizability of findings to other safety net hospitals. First, patient perspectives were not gathered in data collection. Patients may have provided insight on additional determinants and/or diverse perspectives on the current findings. The current study afforded the opportunity of an in-depth exploration through three years of field notes. The clinicians who participated in the consultation meetings were open and reflective adding to the richness of the data. Thus, findings provide an in-depth description of health equity determinants and implementation facilitation strategies. This richness may lay the groundwork for future studies to build on these findings and include the perspectives of patients and other stakeholders. Second, the findings may be limited due to the settings (i.e., integrated primary care, obstetrics, and adult outpatient psychiatry). Replication of findings in other settings would support the conclusions from this study.

Third, there are many approaches to implementation facilitation and the field continues to operationalize the core implementation facilitation skills (Smith et al., 2024). Our IF strategies were used across multiple complex programs (e.g., WET in an OB-SUD clinic and Brief STAIR in an integrated primary care setting). These programs would have had significant implementation challenges without the support of IF. In other settings, the intervention and implementation package may be less complex. Our study aimed to identify IF skills that can be used across settings within the same institution. Identifying which of the IF strategies, used across settings in our institution, are core IF strategies was beyond the scope of this project. Finally, our study may be subject to biases that occurred during consultation and qualitative analysis. All consultation meetings were in an open format and did not include direct interview questions on health equity determinants or facilitation strategies. However, challenges with implementing EBPs were a common topic of consultation. During analysis, we attempted to reduce bias through consensus-building. The analysis was completed by two women-identified trauma psychologists and two RAs receiving mentorship from the former. Personal identities and familiarity with EBPs for PTSD as well as implementation science models may have influenced how data was coded.

Future studies should support the development of an implementation facilitation toolkit to disseminate guidance to novice and early-stage local facilitators. Future research may explore best practices for identifying determinants across settings and for multi-EBP implementation. Further, more research is needed to identify the core implementation facilitation strategies to be used for sustainable multi-EBP implementation. This is one of the first studies to apply the HEIF to guide the analysis of determinants and provide descriptive detail of selected IF strategies. Replication of these findings, in a variety of settings, would strengthen the conclusions. Finally, studies should attend to the complexity of the intervention, context level drivers of inequities (e.g., social determinants of health), and setting. The next step for this line of research is to leverage advisory boards across the ecological framework (e.g., patient-recipients, provider-recipients, community member-recipients). Including advisory board input on facilitation strategies as well as getting support from these key partners to carry out the implementation facilitation plan will further build trust and support the sustainability of these programs such as addressing equity barriers at the context rather than recipient level (Valentine et al., 2022). Though we utilized group consensus building with local change agents to transform determinants data into strategic plan and IF strategies, future studies should utilize a more systematic strategy (e.g., card sorting) to link determinants to implementation facilitation strategies (Lewis et al. 2018) to gather consensus across key partners.

Conclusion

Implementation science has an important role to play in enhancing health equity. Our findings illustrate how assessing implementation and health equity determinants across clinics and EBPs within the same institution can help implementation scientists identify cross-cutting implementation facilitation strategies to improve access to and quality of EBPs for marginalized communities. Targeting cross-cutting implementation facilitation strategies may assist implementation scientists in making a business case for leadership to invest in local implementation facilitation. Our findings also support prior research indicating that crucial health equity determinants for recipients at institutions that serve people of color include stigma and mistrust (LaVeist et al., 2009; Ghafoori et al., 2014; Valentine et al., 2016).

Impact Statement:

The study is the first to apply the Health Equity Implementation Framework (HEIF) in cross-comparison of evidence-based practices (EBPs) varying in intensity, brevity, and delivery within the context of a safety net hospital. We found idiographic intervention-specific barriers and facilitators to implementation. Institution-wide facilitation strategies were then used to enhance implementation, equity, and both access to and quality of services across EBPs and clinics. Findings advance how implementation facilitation strategies can be applied to address both implementation and equity determinants.