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Developing, Implementing and Evaluating Interventions to Reduce Health Disparities
Eliseo J. Pérez-Stable, MDHealth Disparities Research Methods
EPI 222June 6, 2013
Phases of Disparities Research
Detecting: Define health disparities and vulnerable populations
Understanding: Identify determinants and mechanisms of disparities
Reducing Health Disparities•Intervene•Evaluate•Translate/disseminate•Change policy
Adapted from Kilbourne et al., 2006
Phases of Intervention ResearchI. Hypothesis developmentI. Hypothesis developmentII. Methods developmentII. Methods developmentIII. Controlled intervention trialsIII. Controlled intervention trialsIV: Defined population studiesIV: Defined population studiesV: Demonstration / implementationV: Demonstration / implementation
Nationwide prevention and health Nationwide prevention and health services programsservices programs
Categories of InterventionsLifestyle behaviors: Smoking, physical activity,
nutrition, alcohol use, sexual behavior, contraceptive use
Quality of life: Depression, fatigue, pain, sleep, social support, functional status
Decision making: Quality, satisfaction, actionHealth-related behaviors and outcomes:
screening tests, medication adherence, control of chronic disease, birth-weight, falls prevention, vaccinations
Health Services: Reminders, flow-chartsMedications: Differential effects
The Intervention Cycle
Five-Year Relative Survival Rates by Race and Stage, US, 1975-1979 to 1992-1999
Source: Ghafoor, Jemal et al, 2003
Five-Year Relative Survival Rates by Race and StageUnited States (SEER), 1975-1979 to 1992-1999
Source: Ghafoor, Jemal et al, 2003
Possible Explanations for Mortality Differences by Race Different access to early detection
and cure Differential access to best treatment
options Survival is worse because of less
access to follow-up care after treatment
Biological differences –– more triple negative cancers
Behavioral differences: alcohol, HRT
Identifying Intervention Components
Qualitative methodology: focus groups, semi-structured interviews, key informantsBarriers: Access to mammography, lack of or type of health care insurance, transportation, lack of referral, language, lack of information
Facilitators: Reminder systems, support systems, easy access, low cost
Cultural factors: Family, health orientation
Individual factors: Can we ever get 100% of anything?Quantitative methodology: surveys, administrative data, registries
Hazard Ratio of Death in 47,593 women with localized breast cancer, SEER, 1992-2000
LatinaHR 95% CI
WhiteHR 95% CI
Lack PCC Visits
2.3 1.8, 2.7 1.7 1.5, 1.9
PCC Visits 0.9 0.8, 0.9 Ref 1.0
No annual mammogram
7.1 6.0, 8.4 6.4 5.9, 6.9
Annual mammogram
1.0 0.9, 1.1 Ref 1.0
Intervention Design: TheorySelection of a theory: examples
Health Belief Model (perceived susceptibility, severity, benefits, barriers, cues to action, self efficacy)
Trans-theoretical Model (pre-contemplation, contemplation, preparation, action, maintenance)
Precede-Proceed planning model (predisposing, reinforcing, enabling factors)
Intervention Design: TheoryIntervention Design: Theory
Concerns about the applicability of traditional theories to the study of multiethnic populations
Traditional theories emphasize the role of the individual
Latinos and Asian Americans may prioritize family needs over their own
Cultural Leverage in InterventionsCultural Leverage in Interventions Presents health messages in the context
of social and/or cultural characteristics Assume some aspect of targeted behavior
is culturally determined Activates shared norms and expectations Addresses the uniqueness of each culture Adapts the messages to the shared
preferences of specific cultural groups Makes health care system cognizant of
cultural practices–involve community members
Implements interventions by professionals from the targeted groups
MoreGeneric
MoreIndividually
Tailored
Generic interventions
with modifications
Identification of common elements
across cultures
Cultural targeting
Individual cultural tailoring
Culturally-Tailored InterventionsCulturally-Tailored Interventions
Intervention DesignDevelopmentReview existing materials Develop own materialsBasic components
SourceMessageChannelSetting
• Evaluate differences in attitudes, beliefs and behavior regarding cigarette smoking between Latinos and Anglos in population-based sample
• Determine if ethnic differences are independent of education and nicotine dependence
Subjective Culture of SmokingSubjective Culture of Smoking
Cultural Tailoring of Cessation Messages for Cultural Tailoring of Cessation Messages for Latinos: Subjective Culture StudyLatinos: Subjective Culture Study
• Focus on habitual and emotional cues
• Social smoking more important• Family relations, other interpersonal
relations, and personal appearance• Smoking effects on own health and
health of family• Weight gain as an adverse factor?
Multivariate Model Results for Latino Multivariate Model Results for Latino Ethnicity: Reasons to Quit or ContinueEthnicity: Reasons to Quit or Continue
OR 95% CI
Criticized by family 1.93 (1.26, 2.98)
Burn clothes 1.57 (1.02, 2.42)
Children's' health 1.67 (1.08, 2.57)
Bad breath 2.07 (1.40, 3.06)
Family pressure 1.69 (1.10, 2.60)
Good example 1.83 (1.21, 2.76)
Not to gain weight 0.38 (0.24, 0.59)
JGIM 1998; 13: 167-174
Programa Latino Para Dejar de Fumar
• Guia Para dejar de Fumar -- self-help
• Electronic media in Spanish
• Print media limited
• Billboards: bus cards
• Community participation and presence
• Health professionals role?
• Medications?
Guia Para Dejar de FumarGuia Para Dejar de Fumar
Developed in 1987, revised 3 times; in Developed in 1987, revised 3 times; in Spanish, color photos, low literacySpanish, color photos, low literacy
Free on NCI Planet web site, updated Free on NCI Planet web site, updated pharmacological informationpharmacological information
Evaluation from post implementation Evaluation from post implementation showing acceptance and cessation-8.4%showing acceptance and cessation-8.4%
Used as intervention component in Used as intervention component in community studies community studies
Culturally and linguistically tailored– 6th Culturally and linguistically tailored– 6th grade reading levelgrade reading level
Smoking Prevalence in SF Latinos, Smoking Prevalence in SF Latinos, Age 18-64, 1986-89Age 18-64, 1986-89
19861986 19871987 19881988 19891989
(n)(n) (1659)(1659) (2053)(2053) (1965)(1965) (1989)(1989)
MenMen 34.534.5 27.027.0 27.827.8 24.424.4
WomenWomen 17.117.1 17.117.1 16.416.4 12.212.2
Low AccLow Acc 24.824.8 20.320.3 18.918.9 15.315.3
Hi AccHi Acc 24.124.1 22.622.6 25.025.0 21.421.4
Tomando Control 2Tomando Control 2http://stopsmoking.ucsf.eduhttp://stopsmoking.ucsf.edu
Randomized Smoking Cessation Trial on Randomized Smoking Cessation Trial on the Webthe Web
Intent-to-Treat 7-day Abstinence Intent-to-Treat 7-day Abstinence Rates of Internet InterventionRates of Internet InterventionMuñoz RF,Muñoz RF, et al, et al, Nicotine Tobacco Research 2006; 8: 87-97; NTR 2009 11: 1025-34.
6-month quit rates:
Study 1 6.3%
Study 2 (S) 5.6%
Study 3 13.5%
Study 4 (S) 26.0%
Study 5 (80% f/u)Study 5 (80% f/u) 20% at 1 yr20% at 1 yr
Intervention Design: Components
MessageFormat: Packages the contents in ways
likely to appeal to a specific audience
Evidence-based: Enhances the perceived relevance of a health issue to the specific group based on data
Language: Know your audience and adapt to level of literacy, numeracy, Language preference (versatility)
Intervention Design: Tailoring Components
Message: Presents health messages in the context of social
and/or cultural characteristics Population: African American women Promotion of mammography Compared cultural vs. behavioral tailoring
Cultural tailoring ( spirituality, collectivism, racial pride) Behavioral constructs tailoring (knowledge, perceived risk,
perceived barriers) Results: Women who received the behavioral
tailoring were more likely to remember the message than those who received the cultural tailoring (Kreuter et al, 2004)
Women receiving BCT + CRT magazines were more likely than those in the BCT, CRT, and control groups to report getting a mammogram (Kreuter et al, 2005)
Intervention Channels
The mechanism by which the message is delivered
Interpersonal: physicians, friends, counselors, individual attention
Group: classroom activities, webMass media channels: radio, print
media, Internet, mobile technologyInteractive digital media: Web,
Kiosk, games, videos, tablet
Potential Disparities in Intervention Channels
Ethnic media addresses relevant issues to the communities they serve
Access to technology varies by race/ethnic group: Gap may widen
Familiarity with and access to technology
Perceptions of the Internet may vary by race/ethnic group or age
Intervention Design: Setting Places where the intervention can reach the
intended programHomeSchool or workCommunity organizationSupport groups
Times when the audience members may be more attentive
Waiting room Places or situations in which they will find
the message more credibleMedical centers, churches
Intervention Design: Pretesting
Assess comprehensibility (language)
Readability assessmentDetermine personal relevanceIdentify confusing, sensitive, or
controversial elementsAssess attentionContent of the interventionTest the protocols
Evaluation of InterventionsTypes of evaluation
Process evaluation: The process of implementation and how the intervention performed as it takes place.
Mediating variables evaluation: Immediate or early effects on knowledge/attitudes, BP, adherence
Outcome evaluation: assessment of events reflecting long-term effects on events or measures that “matter”
Cancer Screening and PreventionCancer Screening and Prevention
•Apply model to common cancers
•Attitudes, beliefs and behavior
•Predominance of system with screening
•Role of physicians
•Rate of colon and breast cancer lower
•Goal of developing intervention
Misconceptions About Cancer Did Misconceptions About Cancer Did Not Predict Screening BehaviorNot Predict Screening Behavior
• Latinos more likely to have attitudes and
beliefs that may lead to less screening
• Fatalismo reflected in cancer: God’s
punishment, death sentence, little to prevent
• Stigma: not touch person, rather not know
• Beliefs about causes such as bruises, breast
feeding, antibiotics, eating pork, coffee
• Rate of screening in SF Bay Area was similar
Screening Interventions Patient interventions (Masi et al., 2007)
Patient targeted screening trialsReminder lettersWritten educational materialsTelephone callsCulturally tailored classes Videos
Effects were not uniform among all groups Studies among low-acculturated Latinas
demonstrated a positive effect of culturally tailored interventions
Promoting Breast Cancer Screening Clinician interventions (Masi et al., 2007)
Chart reminders and flow sheets Written educational materials Chart audits and feedback Financial interventions
Assistance with financial and logistical needs increased mammography in patient populations that were diverse with respect to race, ethnicity, and insurance status: Dramatic increases associated with vouchers
Clinician interventions led to greater increases in screening mammography compared to patient targeted interventions
Communication of Risk Study 199 women, 65+, 4 race/ethnic groups––45%
Asian, 18% Latina and 12% African American) 68% thought that lifelong screening was either
“important” or “very important”; African American (77%) and Latina (83%)
77% had no plans to discontinue screening 69% had never thought of discontinuing When asked if they would end screening if
recommended by their physician, however, 68% responded “yes”
older age (OR=1.25 per year; CI=1.09-1.44) predictive of ending screening
Sawaya G, et al. Am J Obstetrics Gynecology 2009; 200: 40e1-40e7
Challenges for Intervention Researchers in Disparities
• Come up with innovative interventions that have to be culturally appropriate?
• Design studies that rigorously evaluate interventions without ignoring community priorities and realities?
•Conduct intervention research in a way that builds capacity to eliminate disparities?
• Disseminate an intervention when there is a need to tailor it to the community with the disparity?
Community Health Workers: Efficacy Evidence?Cochrane Review of 43 published randomized
controlled trials (RCT) worldwide (1966-2001): 35 from high income countries; 15 focused on low income and/or minority populations.
Increased immunization uptake in children: RR 1.30 (95% CI 1.14, 1.48)
Improved outcome for acute infectious diseases (respiratory infections and malaria): RR=0.74 (95% CI 0.58, 0.93)
Promising for breastfeeding promotion
Breast Cancer Screening Among Vietnamese AmericansNguyen et al. AJPM 2009
Individual RCT Intervention: 2 small group outreach sessions
conducted by LHW + background media Control: background media
Collaboration with 5 community-based organizations to recruit 50 women LHWs.
9 hour training for LHWs LHWs recruited 1,100 women age 40+
Program Design
RECRECRUITRUIT
RECRUITRECRUIT
Background Media Background Media plus Lay Health plus Lay Health
WorkerWorker
Delayed LHW Delayed LHW InterventionIntervention
InterventionGroups(n=550)
ControlGroups(n=550)
Women(n=1100)
Lay Health Workers(n=50)
Lay Health Worker
Agencies (n= 5)
Background Media OnlyBackground Media Only
Results: Had Last Mammogram WithinPast 2 Years? (% Yes)
% change*: 1.6% vs. 17.4% *p < 0.0001
Multivariate Models for Mammography Receipt
*adjusted for baseline screening status, lay health worker agency, language proficiency, years in the U.S., education, employment, marital status, family history of breast cancer, and household clusters.
44
Breast & Cervical Screening Studies Under the Dominant (Deductive/Quantitative)
Research Paradigm
Breast & Cervical Cancer Intervention Study (BACCIS)1991 – 1996 / NCI R01 R Hiatt
African American, Chinese, Latina, White women
n = 3216
Pathways to Early Cancer Detection in Four Ethnic Groups1992 – 1997 / NCI PO1R Hiatt
African American, Chinese, Latina, Vietnamese, White women
n = 4228
Early Cancer Detection Among Filipina American Women1994 – 1998 / DODM McBride & R Pasick
Filipinas interviewed in Tagalog, Ilocano, Cebuano & Englishn = 875
Cancer Screening, Managed Care & the Underserved “Pathfinders”1998 – 2002 / NCI P01R Pasick & E Perez-Stable
African American, Chinese, Filipina, Latina, & White women
n = 2812
Themes Related to Intention
Meaning of stated intention: for many reasons, people will say yes but mean no
Intention as desirability/politeness: part of respect is being agreeable and not saying no
Intention based on relationship: people will get screened because they perceive that the person asking them truly cares; this is not based on any perceived benefit of the test.
Intention in the absence of beliefs: Patient will form an intention to get screened in the absence of theorized beliefs or knowledge
Association Between Intention at Baseline and Recent Mammography at Final Survey
Race/
Ethnicity N
%
Yes
% Screened
If Yes
% Screened
If No
OR*
95% CI
African American
Chinese
Filipina
Latina
White
All
407
154
121
235
258
1175
86
53
83
87
81
81
72
89
76
68
84
76
61
77
60
53
38
60
1.1 (0.6, 2.1)
1.8 (0.7, 4.6)
1.7 (0.6, 5.0)
1.0 (0.4, 2.2)
5.0 (2.4, 10)
1.7 (1.2, 2.5)
Stewart S, Rakowski W, Pasick RJ. Hlth Ed & Behav Supp 2009
p=0.020 for race/ethnicity-intention interaction; p > 0.05 for all other race/ethnicity interactions
Adjusted for race/ethnicity, age, education, non-English language, years in US, marital status, income, insurance, regular doctor, study arm, months between surveys, baseline screening
Conclusions Beliefs represent what people can
articulate and are conscious of Culture is a powerful influence on behavior
which cannot be understood through beliefs alone
Culture is multi-dimensional, complex, and dynamic; culture is best understood when explored from multiple vantage points
Integrating culture and health behavior should be a transdisciplinary and mixed methods endeavor
RCT of Colon Cancer Screening Strategies
Average risk patients in the SF Community Health Network
997 patients randomized to FOBT, colonoscopy or choice
18% Af Am, 34% Latino, 30% Asian, 15% White; 53% women, 45% LEP, 67% HS+
Outcome: Completion of screening within 12 months
Inadomi JM, et al, Arch Intern Med 2012; 172: 575-582
Colorectal Cancer Screening Adherence
FOBT Colonoscopy Choice /Colonoscopy
African American
56% 34% 54% / 20%
White 55% 47% 70% / 52%
Latino 72% 44% 77% / 24%
Asian 76% 33% 72% / 33%
Housing Vouchers Improve Health
HUD randomly assigned 4498 women living with children in public housing in high poverty area (>40%) from 1994 to 1998
Rent-subsidy housing vouchers to be used to move to low-poverty census tract (≤10%)
Traditional housing vouchers–no restriction Control group received no voucher Baltimore, Boston, NYC, LA or Chicago Follow-up 2008-2010 for health outcomes
Ludwig J, et al. NEJM 2011; 365:1509-19
Neighborhoods Effect on BMI and HbA1C
Control Low-Poverty Voucher
Traditional Voucher
BMI ≥30 58.6 57.5 58.4
BMI ≥35 35.5 31.1 30.8
BMI ≥40 17.7 14.4 15.4
HbA1C ≥6.5%
20.0 16.3 20.6
Conclusions
Interventions design and implementation need to address cultural and individual factors
Cultural leverage may increase the intervention effect
More research is needed to address how much cultural tailoring/targeting is needed
Tailoring may be necessary to reach those at highest risk or with most barriers
Need to do rigorous studies that assess outcome in studies that use cultural leverage
Going Beyond Describing Disparities by Race/Ethnicity We all want interventions that workWe all want interventions that work Need to define mechanisms or Need to define mechanisms or
pathways so we can target effortspathways so we can target efforts Basic research in development of Basic research in development of
intervention contentintervention content Optimal point of interventions: Optimal point of interventions:
community, patients, system, community, patients, system, cliniciansclinicians
Continue to describe and monitor Continue to describe and monitor disparities as natural historydisparities as natural history
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