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Ward MC, Kerr G, Blackstock O, Barnes C, Ogunbajo A, Alberti P. Building the capacity of PCPs to eliminate stigma through a research-informed training model. HPHR. 2024;89. https://doi.org/10.54111/0001/KKKK2
We intentionally centered the voices of historically excluded patient populations in the design of a national primary care practitioner (PCP) training intervention. We sought out patient counter-narratives on HIV/PrEP and COVID vaccine screenings to co-exist with a structured literature review. Doing so allowed our training efforts to understand, disrupt, and reshape systems of power. After our team published a scoping review protocol on both screenings, we identified themes from key informant interviews (n=9) with minoritized patients and PCPs using the Socio-Ecological Model as a theoretical guide for our analysis. Reporting on our research process is beyond the scope of this commentary. Instead, we focus in this paper on what we learned from our research to inform our nine-part PCP training series. Major findings were that PCPs are largely unaware and/or unfamiliar with patient experiences and perceptions of screening; PCPs attend to individual-based, institutional-based, and policy-based facilitators to screening (i.e. overlooking interpersonal-based and community-based facilitators); and patients and PCPs align on the community-based barriers to screening. We developed and implemented a research-informed PCP training series. PCP trainings must be theory-informed and evidence-informed so that learners have the opportunity to become structurally competent in their aims to eliminate stigma.
HIV and COVID-19 are highly stigmatized and disproportionately impact the same patient populations. The Two in One Model was designed as a national research-informed training effort for primary care practitioners (PCPs) to eliminate stigma by routinizing screening for HIV testing and COVID vaccines in the primary care setting.
The Dimensionality and R4P Health Equity Framework offered the equity-based action required to design a training series to address the historical conditions that cause disparate HIV and COVID outcomes among minoritized populations. 1 We conducted HIV (n=49) and COVID (n=19) scoping reviews on screening practices where we used the Socio-Ecological Model 2 to organize our findings-turned-training themes while Critical Race Theory 3 and Queer Theory 4 informed the key informant interviews (n=9) that we conducted to contextualize the training content. Lastly, we relied on a design-based research approach 5 by continuously consulting our National Advisory Board with proposed training content.
We curated a committee of experts to serve as our National Advisory Board who represented specific content knowledge and a range of perspective as patients, residents, clinicians, and government leaders. They also represented a range of racial, sexual, and gender identities. We acknowledge the fullness, complexity and within-group differences of minoritized groups by stating this stance on our website. We also believe it is necessary to name and dismantle colonialism as a way to push back against who gets to create knowledge. As such, our training series includes Black women, patients and community organizers as thought leaders, change agents, and subject matter experts on HIV and COVID-19 prevention who can inform medical education and clinical practice. When creating the program mark/logo, we intentionally used the vibrant colors from the LBGTQIA+ flag. We used this mark on all PowerPoint slides and the recorded videos that branded the program.
Since we started our research with patient and PCP stories, we were able to uncover early on in the project period that there existed a gap in the PCP-patient relationship. We learned that while PCPs focused squarely on the structural factors that affect clinical screening, patients reported the importance of their relationship with PCPs on their screening behaviors. Yet, most notably, we learned that PCPs were largely unaware of their patients’ experience with racism and the level of responsibility placed on patients for deciding if and when to seek care, how to navigate the healthcare system, and what to disclose in exam rooms while experiencing the toll of racism at every turn. We knew there needed to be a specific competency that PCPs could learn to address this phenomenon – and thus the call for culturally responsive communication (CRC) emerged. CRC is the skill that cuts across all modules despite varied training content.
In this commentary, we focus on the research-informed messaging we shared in our PCP training webinar series. We hosted a nine-part research-informed live lecture training series designed for PCPs to build their capacity to eliminate stigma in the primary care setting. From January 2023-November 2023, we were able to reach over 3,000 learners through our live CME-bearing training series. We invited all of the virtual speakers to record never-before-seen content for a self-paced asynchronous online course version of the same training. On March 1, 2024, we debuted 5 of the 9 online standalone modules. The remaining 4 modules debuted on May 1, 2024.
We extended what we learned from our scoping reviews to include 60-minute key informant interviews using the Socio-Ecological Model (SEM) as a theoretical guide.6-7 We conducted nine semi-structured interviews with six patients who identified as minoritized and three PCPs. Below is how we organized and translated our qualitative themes using the SEM into training content for PCPs to support patient screening needs.
PCPs feel largely attuned to their responsibility to self-educate on the enduring impact of racism and heterosexism. They also reported being hyper aware of stigmatizing patient HIV attitudes. However, they admitted that acting on their awareness is circumvented by feelings of burnout. PCP burnout is well-documented for the impact it has on clinician well-being but it also affects the PCP-clinician relationship.8
Our training efforts were designed to curate credible resources in one setting for PCPs to access and receive the support they need to address sociocultural factors weighing in on screening practices. Given the reach of our live series, we have designed a self-paced CME-bearing online course to reach an even broader audience. Each online module includes a welcome video, speaker video content with embedded quiz questions, required readings, supplemental readings and resources such as our patient care toolkit and policy white papers, as well as a retrospective pre/posttest. The total time learners spend in each module is estimated at 60 minutes.
This online training series is designed for clinicians in training (MDs, DOs, PAs, NPs, RNs, PharmDs) and in practice (i.e. students) to value routinizing HIV, PrEP/PEP and COVID vaccine screenings for all their patients. But this content is also applicable to the work of researchers, non-clinician faculty, and scholars who write about and design interventions and policies that impact population health. Eligible clinicians can claim up to 1.0 AMA PRA Category 1 Credit and others can download a certificate of completion.
The application of our conceptual framework resulted in the development of three policy white papers and four clinician vignettes that reached 75,000 clinicians (which we embedded in our training module). Since our original monthly nine-part live webinar reached 3,000 learners, we are confident that our recently debuted asynchronous, self-paced CME-bearing online course will reach an even broader audience. We only assessed reach in our live training and will assess impact in our new online modules. We have presented this training model as six peer-reviewed national conference presentations as well as invited keynote presentations for Meharry Medical College, the American Medical Student Association and the National Medical Association. The research that informed our training series is published as two open-access scoping review protocols6, 12 and the National Advisory Board that vetted all our training content is also presented as a model. 13
We want to thank all of the speakers who contributed to the Two in One Model training series. This program has been supported by an independent educational grant from Gilead Sciences, Inc. The grant funder had no role in the design of this training program.
The authors have no relevant financial disclosures or conflicts of interest.
Dr. Maranda Ward is an Assistant Professor and Director of Equity in the Department of Clinical Research and Leadership in the GW School of Medicine and Health Sciences. She is an expert in advancing anti-racism efforts within health professions education to competently promote health and racial equity in practice. As the PI of the Two in One: HIV and COVID Screening & Testing Model, she led a national research-informed educational intervention aimed at eliminating HIV, PrEP, and COVID-19 vaccine stigma. She earned degrees in sociology and anthropology from Spelman College, in public health from Tulane University, and in education from The George Washington University.
George Kerr III is a patient advocate and member of the DC Center for AIDS Research (CFAR) and the Community Partner Council. He is also a co-community lead for the Drug User Health as well as the committee chair of the Faith, Spirituality, and HIV Committee for the National CFAR CAB Coalition that represents the CFAR. He has a long and committed history of effectively working with some of the most prominent health service providers in Washington, DC and have motivated hundreds of individuals to advocate for those who the stigma of HIV and substance use disorder has silenced.
Oni Blackstock, MD, MHS is recognized as a thought key opinion leader and influencer in the areas of HIV and health equity. She is the Founder and Executive Director of Health Justice, a consultancy that supports healthcare and public health organizations in centering equity in the workplace and reducing health inequities in the communities they serve. Dr. Blackstock is a primary care and HIV physician and researcher who recently served as the Assistant Commissioner at the New York City Health Department where she led the city’s response to ending the HIV epidemic.
Ms. Clover Barnes is a nurse executive with over twenty years of combined experience in healthcare and public health. A champion for health equity, diversity, and inclusion, Ms. Barnes has a demonstrated track record of engaging staff and facilitating change while promoting an organizational culture that supports innovation, collaboration, and data driven decision-making. For seven years, Ms. Barnes served as the Bureau Chief of the Care and Treatment Division of the HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA), where she provided excellent leadership and administrative oversight of the Ryan White Program and DC Health’s Ending the HIV Epidemic Initiatives.
Dr. Adedotun Ogunbajo holds a PhD in behavioral and social health sciences from Brown University, and a MPH and behavioral sciences from Yale University. His research interests are around the intersection of structural barriers and sexual health outcomes among racial and sexual minority communities both in the United States and various Sub-Saharan African countries. He currently serves as the Director of Research at Us Helping Us, People into Living.
Dr. Philip Alberti earned his PhD in sociomedical sciences and his bachelor’s degree in psychology from Columbia University. He founded the Association of American Medical College’s (AAMC) Center for Health Justice as the natural next step in a career focused on eliminating inequities in health and health care. He also currently serves as the AAMC’s senior director of health equity research and policy. Before this, he led health equity research and evaluation efforts alongside community partners for the NYC Department of Health and Mental Hygiene and working as a graduate research assistant with Columbia and the National Center for Children in Poverty.
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