Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT)

Official title

Addressing Clinician Bias to Improve Equitable Implementation of Evidence-Based Practice-Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT)

Overview

Healthcare providers' implicit bias has been identified as a contributor to longstanding health inequities via negative impacts on the patient-clinician relationship and biased delivery of high-quality evidence-based practices (EBP). The implementation of any EBP runs the risk of worsening existing health disparities due to inequitable access, delivery, or benefit of the intervention. Clinician bias can be a critical and unaddressed determinant of implementation for any EBP. Although some implicit bias interventions for healthcare providers are emerging, studies have rarely included mental health professionals. In a previously NIMH funded project, our research team iteratively developed a brief (\~45 minutes), interactive online Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) for school mental health clinicians with promising preliminary findings. The current study will test the effectiveness of VIBRANT-an implementation strategy for promoting equitable adoption, penetration, fidelity, and sustainment of EBPs. One highly learnable, efficient, and scalable EBP that is particularly well-suited for the education sector is Measurement-Base Care (MBC)-the systematic collection of patient-reported progress data to inform clinical decision-making. The proposed study aims to (1) evaluate VIBRANT's feasibility to promote equitable adoption, penetration, fidelity, and sustainment of MBC, with a validated, brief, interactive online training for MBC; (2) examine VIBRANT's impact on proximal mechanisms of change including clinicians' implicit bias as well as distal youth mental health outcomes (i.e., symptoms and functioning) with Black and Latinx youth, and (3) assess feasibility of research procedures for a future large-scale efficacy trial.

Detailed description

Clinician bias constitutes a critical and unaddressed determinant of implementation for any Evidence-Based Practice (EBP). Implicit bias interferes with clinical decision-making and negatively impacts the clinician-patient relationship, leading ethnic/racial minoritized youth to receive suboptimal care resulting in disparate (worse) outcomes compared to their NHW peers. This is a preventable implementation gap (e.g., inequitable adoption, penetration, fidelity, sustainment) that substantially and unjustly limits the reach and public health impact of many of our most well-established EBPs in mental healthcare. This gap is particularly problematic in schools, where access to mental health services is significantly improved for ethnic minority youth, leading to more opportunities for disparate care quality. Despite the established knowledge base on implicit bias and bias reduction strategies, very little research has been done with mental health professionals; our team's previous work constitutes the first studies with mental health providers in the school setting. To address this gap in implicit bias intervention research and the lack of equity-focused implementation strategies, the investigators are conducting a pilot Hybrid Type 3 Effectiveness-Implementation Trial of a Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT)-a highly efficient (\~45 minutes), usable, and scalable intervention (interactive online training module) to address implicit bias among school mental health clinicians and support the equitable implementation of EBPs.

With previous NIMH funding, VIBRANT was iteratively developed for school mental health clinicians employing user-centered design principles. In a small proof-of-concept study (N = 12), school mental health clinicians found VIBRANT to be highly usable, appropriate, acceptable, and feasible to implement in their clinical practice. After completing the VIBRANT training, clinicians demonstrated notable improvements in implicit bias knowledge, and a downward trend in implicit bias (as measured by the Implicit Association Test) over 14 weeks. Moreover, clinicians with the greatest reductions in implicit bias also reported the strongest alliance with their youth patients. These results from our preliminary studies suggest that VIBRANT is an efficient and highly usable implementation strategy that holds promise for addressing clinician implicit bias to promote equitable implementation of other highly scalable evidence-based interventions.

Although VIBRANT is EBP-agnostic, it will be tested in the context of measurement-based care (MBC) implementation given (1) the high potential for MBC to optimize school mental health services, but currently inconsistent use in school mental health, and (2) MBC's vulnerability to inequitable delivery. Specifically, this study will evaluate the preliminary effectiveness of VIBRANT as an equity-focused implementation strategy for MBC. In addition to assessing VIBRANT's impact on equitable MBC adoption, penetration, fidelity, and sustainment within and between clinician caseloads, the investigators will also examine impact on proximal mechanisms of change (clinician implicit bias, therapeutic alliance) and distal youth clinical and functional outcomes.

Interventions

• Behavioral Brief Online Training (BOLT) for measurement-based care (MBC)
  Brief Online Training (BOLT) for measurement-based care (MBC) is a series of 4 interactive, self-paced, online training modules that takes approximately 75 - 120 minutes to complete. Clinicians are trained on the core functions, procedures, and best practice approaches for delivering MBC in the school mental health setting. MBC is the systematic collection of patient-reported data to support collaborative clinical decision-making from intake to termination.
• Behavioral Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT)
  The Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) is a brief (45-minute), self-paced, interactive online training module designed to help school-based mental health clinicians understand and manage their implicit bias in clinical interactions.
• Behavioral Live Post-Training Consultation
  Two 1-hour long small group consultation sessions with an expert consultant designed as additional opportunities to support knowledge elaboration and skills generalization.
• Behavioral Asynchronous Discussion Board
  An expert facilitated online Discussion Board for additional opportunities of knowledge clarification, practice reinforcement, and community building to support implementation sustainment.

Primary outcome measures

• Adoption of Measurement-Based Care (MBC) strategies [Time frame: 4-month (follow-up 2)]
• Penetration or saturation of Measurement-Based Care (MBC) strategies use [Time frame: 4-month (follow-up 2)]
• Sustainment of Measurement-Based Care (MBC) strategies use [Time frame: 4-month (follow-up 2)]
• Fidelity of Measurement-Based Care (MBC) Strategies use [Time frame: 4-month (follow-up 2)]
• Change in Clinician's Implicit Association Test (IAT) Scores [Time frame: 0-months (Pre-training), 1-month (post-training), 2-month follow-up 1, and 4-month (follow-up 2)]
• Change in Clinician and Youth Working Alliance Inventory--Short Form scores [Time frame: 1-month (post-training), 4-month (follow-up 2)]
• Change in Strengths and Difficulties Questionnaire (SDQ) youth and caregiver report scores [Time frame: 1-month (post-training), 4-month (follow-up 2)]

Eligibility criteria

Inclusion criteria

Inclusion criteria for each of the subjects participating in the study as follows:

• Participating clinicians must…

• Provide school-based mental health services in middle and high school settings for at least 50% of their clinical deployment.
• Provide on-going 1:1 mental health services to students (e.g., not assessment only).
• Have a caseload (who is receiving on-going care) that consists of at least 20% of Black or Latinx students.
• Participating youths must…

• Identify as Black/African American or/and Hispanic/Latina/Latino/Latinx
• be entering into ongoing treatment with a participating clinician in the school mental health setting
• Participating caregivers must… a. be a primary caregiver to the youth who can answer questions about the youth's daily behaviors and emotional well-being

Exclusion criteria

Exclusion criteria for each of the subjects participating:

• School-based mental health clinicians

• Clinician who previously participated in a measurement-based care (MBC) related study with our team and have already been exposed to our online MBC training.
• Clinicians who have participated in a previous study related to VIBRANT.
• Black \& Latinx youth

• Youths with a developmental or learning disability that would interfere with their ability to accurately give informed consent or assent and reliable completion of study assessments.
• Youths who do not speak English or Spanish
• Caregivers

• Caregivers who do not reside with the youth or would otherwise have adequate daily contact to report on the youth's typical behaviors and/or emotional well-being.
• Caregiver who do not speak English or Spanish

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: Yes

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Single blind

Primary purpose

Health services research

Study locations

United States · 1 center

• University of Washington — Seattle

Publications

• Liu FF, Coifman J, McRee E, Stone J, Law A, Gaias L, Reyes R, Lai CK, Blair IV, Yu CL, Cook H, Lyon AR. A Brief Online Implicit Bias Intervention for School Mental Health Clinicians. Int J Environ Res Public Health. 2022 Jan 7;19(2):679. doi: 10.3390/ijerph19020679. PMID 35055506
• Liu FF, McRee E, Coifman J, Stone J, Lai CK, Yu CL, Lyon AR. School Mental Health Professionals' Knowledge of Stereotypes and Implicit Bias Toward Black and Latinx Youths. Psychiatr Serv. 2022 Nov 1;73(11):1308-1311. doi: 10.1176/appi.ps.202100253. Epub 2022 Jul 20. PMID 35855619
• Lyon AR, Liu FF, Connors EH, King KM, Coifman JI, Cook H, McRee E, Ludwig K, Law A, Dorsey S, McCauley E. How low can you go? Examining the effects of brief online training and post-training consultation dose on implementation mechanisms and outcomes for measurement-based care. Implement Sci Commun. 2022 Jul 22;3(1):79. doi: 10.1186/s43058-022-00325-y. PMID 35869500

Identifiers

NCT: NCT05970991 · STUDY00016173 · 1R34MH128386-01A1

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗