Using the Organizational Readiness to Change Theory to Understand the Implementation of a Tobacco-Cessation Program in Homeless-Serving Agencies: A Qualitative Study
Introduction
Despite high tobacco use rates (~70%), and tobacco-related cancers being a major cause of morbidity and mortality for those experiencing homelessness, clients of homeless-serving agencies are rarely treated for tobacco dependence. While evidence-based, tobacco-cessation interventions have proven effective and are desired in this group, limited staff knowledge on how to treat tobacco dependence and support quitting remain key barriers to intervention adoption. This qualitative study explored factors enabling and inhibiting the implementation of a comprehensive, evidence-based tobacco-free workplace (TFW) program consisting of TFW policy implementation, specialized provider training on treating tobacco dependence, and provision of free resources (e.g., nicotine replacement therapy (NRT), dissemination materials), within homeless-serving agencies.
Methods
From January 2022 – July 2023, semi-structured individual and group interviews were conducted virtually with providers (N=12) from three homeless-serving community agencies serving three counties. Agencies were small, with 2-6 direct-service providers, jointly serving 1,355 unique clients annually. Pre-implementation interviews focused on tailoring the intervention to specific agencies, and post-implementation on understanding program effectiveness. Interviews were audio-recorded and transcribed verbatim. Initially, two analysts independently coded transcripts inductively, using thematic analysis and constant comparison. Coding discrepancies were reconciled by negotiated consensus until the codebook was finalized and reapplied to all transcripts. To better understand the factors influencing program implementation, constructs from the Organizational Readiness for Change theory (change commitment, change efficacy, and contextual factors) were then used to further interrogate and refine final themes.
Results
Data analysis yielded three main themes with 11 categories acting as enabling (E) or inhibiting (I) factors to implementation. From pre- to post-implementation, agencies faced increases in existing challenges or additional ones, contributing to program partner attitudinal changes, wherein many factors previously functioning as enabling were reframed as inhibiting (E/I; e.g., loss of program-buy-in, motivation to change). I. Change commitment: pre-implementation, providers voiced high 1) program buy-in (E/I), 2) motivation to change (E/I), and 3) appreciation of benefits for clients (E). II. Change efficacy: Initially, 4) valuing training to treat client tobacco use was high (E/I), as was 5) TFW policy support (E), and 6) perceived fit with agency cultural values (E/I). While providers expressed significant commitment and change efficacy pre-implementation and valued program tailoring to local contexts, changing contextual factors resulted in considerably limited implementation, or program withdrawal (N=1), by post-implementation. III. Contextual factors: included 7) high staff turnover (I), 8) leadership attitudes/changes (E/I), 9) lack of resources (I), 10) contending priorities (e.g., high case-loads) (I), and 11) COVID-19 related issues (I).
Conclusion
Changing contextual factors adversely impacted implementation despite flexible implementation focused on increasing adaption to local contexts, provision of provider training on treating tobacco use, and free NRT. This study indicates small, under-resourced community-based agencies may not be sufficiently resilient to recuperate from infrastructure challenges to regain the stability needed to successfully implement a comprehensive TFW program. Findings contribute to implementation research by stressing that as organizational readiness for change is a contingent and thus, unstable state, low-resourced agencies require additional support, guidance, and innovation to build the capacity required to implement change.