Understanding the impact of external context on community-based implementation of an evidence-based HIV risk reduction intervention

Background: Organizational context plays a critical role in the implementation of evidence-based interventions. Implementation research to date has focused largely on internal, rather than external, context. This paper presents key features of external context and their impact on implementation of Eban II, an evidence-based HIV/AIDS prevention intervention currently being tested in community-based organizations (CBOs). We examine external context factors that have influenced implementation, highlighting the ways in which client needs, agency resources, and changing policies permeate the theorized boundary between internal and external context, affecting both organizational capacity for implementation research and implementation processes themselves. Methods: Staff (n = 91) across participating CBOs completed a baseline survey of organizational functioning; a subset of key stakeholders (n = 15) completed semi-structured interviews. Client participants (n= 84) completed a baseline survey. Process notes and organizational documents were also analyzed. Results: Organizational readiness for implementation was high across the organizations. However, despite apparent readiness, external contextual barriers to implementation were substantial. Three categories of barriers were identified: (1) client needs as a manifestation of social determinants of poverty, (2) community agency resources, and (3) local and national policy changes. Clients’ psychosocial vulnerability affected their everyday lives and priorities, which thereby affected the regularity and intensity of their interface with CBOs, and hence their participation in our intervention. CBOs typically lacked staffing and space. Furthermore, changing federal and state policy priorities destabilized the CBOs, which had a ripple effect on our study. Drawing on community-engaged research principles, we made numerous adjustments to the intervention format and structure according to the preferences and contexts of the CBOs. Had we not adjusted to external contextual factors, the organizations would not have been able to maintain their involvement and provide the intervention to their clients, despite expressed, genuine commitment to shared goals. (Continued on next page) * Correspondence: [email protected] UCLA Department of Psychiatry and Biobehavioral Sciences, 760 Westwood Plaza, 38-240 NPI, Box 175919, Los Angeles, CA 90024-1759, USA VA Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hamilton et al. BMC Health Services Research (2018) 18:11 DOI 10.1186/s12913-017-2791-1