Practitioner Exposure to Behavioral Interventions Predicts Adoption and Referrals to Evolving Biobehavioral Innovations in a Systems-Level Model – CDC Diffusion of Effective Behavioral Intervention

Background and Purpose: This paper focuses on the longest-running (20 years) system-level implementation effort in the U.S., the CDC Diffusion of Effective Behavioral Intervention (DEBI) program, which involves dissemination and implementation of effective HIV-prevention behavioral interventions (EBIs) to reduce morbidity, mortality and health disparities. Current CDC mandates require practitioners to adopt and increase referrals to biobehavioral interventions (HIV, STI, Hep C testing/treatment) and support services (substance abuse, mental health, primary care) for HIV-positive and high-risk persons. This mandate reflects the WHO’s emphasis on integration of services and recent research showing that integration (e.g., referrals to interconnected services) can lower HIV transmission rates. We believe ours is the first study asking if practitioners’ exposure to EBPs (20 years of CDC-EBIs) is associated with integration (multiple referrals) of biobehavioral interventions. We hypothesize that exposure to CDC-EBIs—defined as practitioner reports of EBIs provided by agencies—increases practitioner referral-making.  

 Methods:  Baseline data:  300 practitioners from longitudinal, NIMH-funded study (5R01MH095676) in 33 agencies in NY City funded by Department of Health to provide HIV prevention/treatment. Agencies budgets ranging from $500,000 to several million. One-third have ≤25 staff; one-third have 26-100; one-third have >100. Sample: Case managers (29%); outreach workers/navigator (24%); counselors (18%); supervisors (15%); project managers (14%). Education: BA (34%); Master’s (28%); HS (24%); Associate (13%); Less than HS (1.5%); PhD (1%). Mean age: 41 (SD=12). Gender: Females (63%). Race/ethnicity: Black (51%); Latino (38%); White (6%); Asian/Pacific Islander (5%). Outcome Measure: How often practitioners referred clients in the past six months to HIV, HEP-C and STI testing, primary care, substance abuse treatment, mental health and syringe exchange programs. Exposure to DEBIs: Participant agency offered EBIs. If “yes,” practitioners considered “exposed.” Controls: age; gender; race; work category; education.

 Analysis: Frequency of referrals (four ordered categories—“No referrals” to “several times a week”). Primary predictor: Participants’ report of exposure to CDC-EBI (dichotomous). Nesting of providers within agencies controlled with random effect for agency. Ordered logistic regression reflected four ordered categories measuring frequency of referrals. Odds ratios interpreted as odds of making more referrals (i.e., higher category), given exposure to CDC-EBI.

 Results: Practitioners exposed to at least one EBI were more likely (p < .05) to refer to HIV (OR=1.98), HEP-C (OR=3.53) and STI testing (OR=1.87), substance abuse treatment (OR=2.23) and mental health programs (OR=1.75). After controlling for the availability of these services at participants’ agencies, we found that the average rate of referrals is basically the same, whether or not the agency offers that service.

 Implications: Limitations: local diffusion system; cross-sectional study; practitioner self-report. This limits our ability to show causality and hinders generalizability. Still, practitioners exposed to EBPs are more likely to refer to other EBPs currently emphasized by the CDC. DEBI was a major first step toward evidence-based public health: exposure to early EBIs increases referral to (and subsequent consumer use of) newer EBIs. These data provide evidence of a system-level evolution of new EBPs and illustrates a unique interplay between exposure to EBPs and referral-making to other EBPs.