INTRODUCTION:
Despite advances in diagnosis and management, disparities exist in the burden of end-stage kidney disease (ESKD) such that Black patients in the U.S. experience almost a 4x higher incidence than white patients.1 Structural racism has been implicated as a driver of these racial disparities, suggesting the need to intervene on inequitable structures within the healthcare environment. This paper describes how we used the 6SQuID framework2 to develop such an intervention.

METHODS:
We completed 5 steps of the 6SQuID framework: 1) Define and understand the problem and its causes, 2) Clarify which causal factors are malleable and have greatest scope of change, 3) Identify the most appropriate change mechanism, 4) Identify how to deliver the change mechanism, and 5) Test and refine on a small scale. The 6th step (Collect evidence of effectiveness) is beyond the scope of this paper.

RESULTS:
We report results of each of the 5 steps: 1) We used Public Health Critical Race Praxis (PHCRP) to identify structural drivers of the underlying disparity that are rooted in structural racism.3,4 2) We created a causal pathways diagram documenting how socio-cultural, institutional, operational, organizational, interpersonal, and individual factors drive Black patients’ progression to ESKD. 3) We used the Chronic Care Model,5,6 PHCRP, and input from our Community Advisory Board to settle on a kidney health coaching (KHC) intervention that would engage patients in shared healthcare decision-making. 4) We developed the KHC training manual and curriculum and an electronic platform for documenting KHC activities in the electronic medical record. 5) We pilot tested and made adjustments to the 12-session curriculum.

CONCLUSIONS:
This paper applies a theoretically grounded process for developing an intervention that seeks to mitigate against the effects of structural racism on ESKD disparities. This KHC intervention was developed to facilitate adaption at healthcare systems beyond our own.