The ‘Race/Ethnicity Variable’ is not the full story: a structural account of factors influencing provider attitudes about contingency management

Recent studies have documented racial/ethnic differences in provider attitudes toward contingency management (CM). A limitation of prior work, however, has been the failure to consider the effect of race/ethnicity in the context of other provider identity characteristics and organization-level factors. To extend prior work, we conducted a secondary analysis of CM providers to determine whether racial/ethnic differences would be replicated and the contribution of other provider identity characteristics and organization-level variables to CM attitudes. 186 providers across 28 sites were enrolled in the parent trial. Prior to deploying implementation strategies, provider and organization characteristics were assessed using baseline surveys. CM attitudes were assessed as outcomes using three brief scales (General CM Impressions, CM Acceptability, CM Effectiveness). Study hypotheses were addressed via sequential regression models with Omnibus tests of model fit. Twenty out of twenty-eight opioid treatment programs enrolled providers identified as racial/ethnic minorities. No main effect differences on CM attitudes were found by racial/ethnic identity in unadjusted analysis. The best-fit model included covariates for organizational characteristics and did not contain any other provider characteristics, revealing that racial/ethnic minority providers rated CM effectiveness lower than non-Hispanic White providers. Additionally, implementation climate and leadership engagement were significant predictors of CM attitudes, such that higher perceptions of both variables predicted more favorable attitudes. A comprehensive understanding of providers’ attitudes can promote successful adoption of an intervention. When accounting for broader organizational context, racial/ethnic group differences of perceived CM Effectiveness fully came into view, suggesting that racial identity and organizational factors operate jointly to influence provider attitudes towards CM. Implementation strategies should address diverse perceptions of CM effectiveness through educational/training strategies as well as strategies designed to modify organization-level factors (e.g., implementation climate and leadership engagement). The parent trial is registered in Clinicaltrials.gov (NCT03931174).