An Unexplored Equity Factor During Pre-Implementation of Contingency Management: Differential Beliefs and Attitudes by Providers’ Ethnicity

Background Although considered one of the most effective interventions for substance use disorders (SUD), the widespread uptake of contingency management (CM) has remained limited. Prior studies at the provider-level have explored beliefs about CM among SUD treatment providers and have tailored implementation strategies based on identified barriers and training needs. However, there have been no implementation strategies that have actively sought to identify or address potential differences in the beliefs about CM that could be influenced by the cultural background (e.g., ethnicity) of treatment providers. To address this knowledge gap, we examined beliefs about CM among a sample of inpatient and outpatient SUD treatment providers. Methods A cross-sectional survey of SUD treatment providers was completed by 143 respondents. The survey asked respondents about their attitudes toward CM using the Contingency Management Beliefs Questionnaire (CMBQ). Linear mixed models were used to examine the effect of ethnicity on CMBQ subscale (general barriers, training-related barriers, CM positive-statements) scores. Results Fifty-nine percent of respondents self-identified as non-Hispanic White and 41% as Hispanic. Findings revealed that SUD providers who identified as Hispanic had significantly higher scores on the general barriers (p < .001) and training-related barriers (p = .020) subscales compared to the non-Hispanic White SUD providers. Post-hoc analyses identified differences in the endorsement of specific individual scale items on the general barriers and training-related subscales. Conclusions Dissemination and implementation strategies for CM among treatment providers need to consider equity-related factors at the provider-level that may be associated with the adoption and uptake CM.


Introduction
Contingency management (CM) is an evidence-based intervention for substance use disorders (SUD) that provides positive reinforcement (e.g., prizes, vouchers, gift cards) for targeted behaviors such as abstinence or the reduction of substance use (Rash et  Although previous research has demonstrated the effectiveness of CM in multiple practice settings, the widespread uptake of CM has been slow. In the uptake schema, the pre-implementation phase is characterized as the work needed to understand organizational and provider readiness (Ellis et al., 2020;Simpson, 2002). Among providers, readiness includes understanding, knowledge, and beliefs about an intervention (Ball et al., 2002;McGovern et al., 2004). Treatment providers' beliefs and attitudes towards CM have been well documented and are an important individual-level factor that can impede or facilitate implementation (Oluwoye et al., 2019).
Some studies have found negative attitudes towards the philosophical underpinnings, operational cost, lack of training, and limited knowledge about CM as barriers among SUD treatment providers (Benishek et al., 2010;Ducharme et al., 2010;Kirby et al., 2006). Further, certain provider characteristics, such as educational attainment and years of experience, have also been shown to in uence beliefs about CM (Kirby et al., 2006;Srebnik et al., 2013). Based on what is known about providers' beliefs and attitudes towards CM, implementation strategies have been developed to include pragmatic training components to target many of these factors, such as lack of training (e.g., CM delivery) and limited knowledge (e.g., theoretical underpinnings of CM) (Oluwoye et al., 2019). However, many of these earlier studies examining beliefs and attitudes toward CM and assessing implementation strategies have not considered equity-related factors such as the race and ethnicity of providers. It is, therefore, unknown whether this speci c provider-level characteristic affects beliefs and attitudes toward CM which will subsequently impact implementation success.
In other behavioral health elds, there has been a few studies that have found an association between the race and/or ethnicity of providers and attitudes towards the general use of evidence-based interventions.
For instance, Aaron and colleagues' ndings suggest that Black and Hispanic providers report more negative attitudes toward evidence-based interventions compared to White providers (Aarons et al., 2012(Aarons et al., , 2010. In contrast to these studies, one study found that Hispanic providers reported more positive attitudes toward evidence-based interventions in community mental health settings (Ramos et al., 2020).
To our knowledge no studies have explored the relationship between providers' race and/or ethnicity and their beliefs about CM, in particular. Thus, the purpose of this study was to conduct a survey to characterize beliefs about CM among a racially/ethnically diverse sample of SUD treatment providers in community-based settings.

Participants and procedures
Potential participants were eligible if they were 18 years of age and older, self-identi ed as currently or previously employed as a provider in an addiction treatment clinic, and reported English language uency. Potential participants did not need to have prior experience with CM to complete the online survey. Between January 2019 and June 2019, a total of 203 potential participants responded to a targeted email disseminated to professional groups focused on SUD and addiction (i.e., Addiction Drug and Alcohol Institute), who were asked to also share it with other networks. Of those who initially responded, 162 respondents met inclusion criteria, with 143 providing responses on the CMBQ, for a participation rate of 88.3% (The American Association for Public Opinion Research., 2016).
To facilitate survey completion, a Research Electronic Data Capture (REDCap)-based electronic survey was used to capture responses from eligible participants and the survey link was embedded in the email distributed to listservs. The result was an "opt-in" nonprobability sample based on participants recruited through the professional group listserv sampling frame. This study was considered exempt by the university's Institutional Review Board and participants were asked to read and download informed consent forms, and indicate whether they would like to continue to the survey. At the end of the survey, participants were asked to provide their email address to receive a $15 e-gift card for survey completion. The survey was closed after six-months of recruitment and all data were maintained in a secure electronic database.

Contingency Management Beliefs Questionnaire
The 32-item Contingency Management Beliefs Questionnaire (CMBQ) was used to assess the level of in uence each item has on providers' decision to adopt the use of CM on a ve-point Likert scale (0 = no in uence at all; 1 = very little in uence; 2 = some in uence; 3 = strong in uence; 4 = very strong in uence). Exploratory and con rmatory factor analysis of CMBQ item scores suggests a stable and reliable three factor structure forming three subscales totaling 32 items: General Barriers (17 items

Demographics
Data were also collected on key demographic characteristics, such as age, gender (male, female, transgender, or nonbinary of which respondents only selected male or female thus creating a binary variable), race (White, Black/African American, Asian, American Indian/Alaska Native, Native Hawaiian or Paci c Islander, Other), ethnicity (non-Hispanic or Hispanic), licensed mental health counselor (LMHC) credential status (yes/no), and graduate degree status (yes/no).

Data analysis
Among all respondents, 49% self-identi ed as non-Hispanic White, 34% as Latinx, 7% as Black, and 10% as an ethnoracial minority. Based on the sparse representation of races and ethnicities other than non-Hispanic White and Hispanic ethnicity, we limited our analyses to these two groups in order to avoid error in interpretation from very small subsamples of other races. Demographic comparisons among non-Hispanic White and Hispanic respondents were appropriate to the scale of measurement: age was compared with independent sample t-tests with all other demographic variables analyzed in two-way contingency table analyses using exact tests to assess for signi cant differences in proportions by ethnicity. For inferential testing, CMBQ subscale sores were converted to the mean scale score by summing scores for all items completed within a scale and dividing by the number of items completed in the scale. Averaging standardized scales (composed of different numbers of items) for comparison and compensated for the limited amount of non-response within a few respondents, as detailed in the Results section.
A linear mixed model was used to examine the effect of ethnicity on mean CMBQ subscale scores. Ethnicity was modeled as a binary xed factor with the each CMBQ subscale scores, representing levels of a second xed repeated measures factor -scale. The ethnicity and scale interaction term was also modeled as the primary parameter of interest in order to evaluate whether scores on each subscale differed among non-Hispanic White and Hispanic respondents. The initial fully speci ed model included all demographic variables that differed signi cantly by ethnicity in univariate analyses as covariates (i.e., age, gender, credential status, graduate degree status). A second, more parsimonious, model was developed that removed gender and credential status from the model as these were not signi cant as covariates in the fully speci ed model (p = .941 and p = .322, respectively). Graduate degree status and age were maintained as covariates in the second model. Model t to the data improved in the second model based on a reduction in Akaike's Information Criterion. Both models employed random intercepts for respondents to account for correlation between CMBQ subscales, restricted maximum likelihood estimation, and modeled covariance structure as a scaled identity matrix; both models converged under these criteria.
A signi cant ethnicity by CMBQ subscale interaction was followed up with simple main effects tests to determine which scales differed by ethnicity. Post-hoc analyses were conducted on CMBQ subscales that differed by ethnicity using a scale-item by scale-item follow up 2 by 2 (ethnicity by dichotomized item scale score ['some to very strong in uence' vs. 'very little to no in uence']) exact tests to explore differences in speci c attitudes toward CM among Hispanic and non-Hispanic White respondents. All analyses used two-sided type I error rates of p < .05, and were conducted with SPSS, v. 28.0.

Participant characteristics
Overall (N = 143), the mean age was 41.0 years, 59% (n = 85) self-identi ed as non-Hispanic White and 41% (n = 58) as Hispanic. As seen in Table 1, non-Hispanic White respondents were signi cantly older and had signi cantly more female providers than participants who identi ed as Hispanic. A signi cantly higher proportion of Hispanic respondents were LMHC credentialed, while a signi cantly higher proportion of non-Hispanic White respondents had graduate degrees. The majority of respondents in both groups worked in addiction or mental health agencies, and most worked in outpatient settings. Interaction means derived from linear mixed modeling are displayed in Table 2.

Differences in Individual Items on General and Training-Related Barriers Subscales
For each of the 17 items in the General Barriers subscale, signi cantly higher proportions of Hispanic respondents endorsed "some to very strong in uence" compared to non-Hispanic White respondents (all p-values ≤ .036). Items with the greatest differences in endorsement among groups (> 40% difference in group proportions) included external barriers (e.g., clients already abstinent so don't need CM and clinics prevent urine screening) and internal barriers (e.g., provider nding CM distasteful and clinical experience more important than research evidence). Differences in endorsement of individual subscale items are displayed in Table 3.
On the Training-Related Barriers subscale, signi cantly higher proportions of Hispanic respondents endorsed "some to very strong in uence" than non-Hispanic White respondents need for more CM training (p = .023). Similarly, a signi cantly larger proportion of Hispanic respondents felt their agencies/administrations posed barriers to provision of CM (p = .005) relative to their non-Hispanic White counterparts.

Discussion
Findings from our study revealed valuable insights into the variability of attitudes among providers of different ethnicities towards CM as an evidence-based intervention for SUD. Although there has been limited CM research intentionally focusing on equity factors (e.g., ethnicity) at the provider-level, our ndings align with prior work in other areas that have signaled the potential importance of providers' ethnicity on beliefs and attitudes (Aarons et al., 2012(Aarons et al., , 2010Ramos et al., 2020), which is key to designing and re ning implementation strategies.
Broadly, understanding providers' beliefs and attitudes during the pre-implementation phase is linked to the successful adoption and uptake of an intervention. This also includes identifying whether there are gaps or differences among providers, so that implementation strategies are tailored appropriately. Previous studies have cited that failure to adequately understand providers' attitudes can hinder the successful implementation of an intervention (Ellis et al., 2020). A single study examining ethnoracial differences in the adoption of CM reported lower CM adoption rates among SUD providers who identi ed as an ethnoracial minority than among non-Hispanic White providers (Helseth et al., 2018). Our ndings, along with limited prior work, collectively demonstrates that it is not enough to simply tailor implementation strategies to t within the practice context. Instead, our results support the need to tailor implementation strategies for ethnoracial characteristics of SUD providers. Because few studies have examined equity-factors beyond the client level, further research is needed to determine how to improve uptake and use of evidenced-based interventions among ethnoracially diverse providers.
The eld of implementation science has more recently called for equity-focused practices in the design and roll-out of strategies (Baumann and Cabassa, 2020; Shelton et al., 2020). Notwithstanding, there has been limited direction on how implementation strategies that include training and supervision can be tailored. For example, to moderate negative attitudes towards CM, it could be that evidence surrounding effectiveness of CM for initiating abstinence among ethnoracial minorities needs to be further highlighted in initial training. Storytelling videos that capture client and provider experiences engaging in a CM program, implemented in ethnoracially-speci c settings could also be incorporated and widely disseminated among providers. During the pre-implementation phase, community participatory approaches that include providers as stakeholders should be incorporated to align CM practices with cultural values, which has been shown to be useful in Tribal communities .
Among study limitation is the use of a convenience sample of SUD providers. Based on this, caution should be used when generalizing to other SUD treatment providers. Further, the small number of respondents from Black, American Indian/Alaska Native, and Asian respondents suggests that these results should not be extended to other races. As such future research should examine differences in attitudes and beliefs about CM in a more diverse sample of SUD treatment providers.

Conclusions
This study highlights the need for consideration of Hispanic ethnicity as an equity factor at the providerlevel, which has not been previously acknowledged during the pre-implementation phase. Understanding the possible in uence of providers' ethnoraical background on the perceived advantages and disadvantages of CM is fundamental to developing equity focused implementation strategies that may aid the adoption of CM among SUD treatment providers.

Declarations
Ethics approval and consent to participate.
This study was conducted in accordance with the Declaration of Helsinki, and study procedures were reviewed and approved by Washington State University's Institutional Review Board (#17391).
Participants were fully informed about study purpose and procedures. All participants provided informed consent prior to completing the online survey.

Consent for publication
Not applicable Availability of data and materials The data analyzed for current study is available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests. Disclosure statement No con ict declared.