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Issues in Development and Evaluation of Interventions to Reduce Health
Disparities
Eliseo J. Pérez-Stable, MDHealth Disparities Research Methods
EPI 222June 3, 2010
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 Research I. Hypothesis developmentI. Hypothesis development II. Methods developmentII. Methods development III. Controlled intervention trialsIII. Controlled intervention trials IV: Defined population studiesIV: Defined population studiesV: Demonstration / implementationV: Demonstration / implementation
Nationwide prevention and health Nationwide prevention and health services programsservices programs
Interventions Types of interventions
Lifestyle behaviors: Smoking, exercise, weight loss, alcohol use, contraceptive use
Quality of life: Depression, fatigue, pain, sleep, social support
Decision making Health-related behaviors and outcomes:
screening tests, medication adherence, A1C, BP control, birth-weight, falls
Health Services: Reminders, flow-charts
The Intervention Cycle
The Intervention Cycle
1.Problem
Identification
Five-Year Relative Survival Rates by Race and StageUnited States (SEER), 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
Use of Mammography in the Last Two Yearsfor women 40 years of age and over, by race and Latino origin
Source: National Center for Health Statistics, 2005
Problem Identification Qualitative methodology (focus groups, semi-
structured interviews, key informants)
Barriers Access to mammography, insurance, transportation,
lack of referral, language, lack of information
FacilitatorsReminder systems, support systems
Cultural factors: Family, health orientation
Individual factors Quantitative methodology (surveys)
Intervention DesignIntervention Design
Identify strategy and theory
Develop messages and materials
Test the intervention
Intervention Design: TheorySelection of a theory: examples
Health Belief Model (perceived susceptibility, severity, benefits, barriers, cues to action, self efficacy)
Transtheoretical Model (pre-contemplation, contemplation, preparation, action, maintenance)
Precede-Proceed planning model (predisposing, reinforcing, enabling factors)
Intervention DesignIntervention DesignTheory
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
Intervention DesignIntervention Design To what extent is the targeted behavior
culturally determined?
What are the most effective routes to reaching the population?
Must the content of the educational message address cultural factors?
Involvement of community member Research conducted by representatives of
the culture Qualitative methods
Intervention DesignIntervention DesignCultural leverage (Fisher et al, 2007)
Presents health messages in the context of social and/or cultural characteristics
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 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 DesignIntervention Design
Cultural targeting Strategies to try to reach group
members who share certain values, beliefs, and practices
Cultural tailoring Customizes messages based on an
individual status (e.g., level of spirituality, collectivism, racial pride)
Intervention DesignDevelopment Review existing materials
Example: Breast cancer risk assessment programs
Develop own materials Basic components
Source Message Channel Setting
Intervention Design: Components
SourceCommunity leadersCommunity health workers (promotoras)
NavigatorsHealth educatorsPhysicians
Intervention Design: ComponentsSource
Example: Witness Project in rural Arkansas
Witness role models (cancer survivors) led small discussion groups
Discussion of cancer experiences at churches and community settings
Self-reported breast self examination and mammography rates increased significantly from baseline to six months
Erwin et al., 1999
• 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
QuickTime™ and aPhoto - JPEG decompressor
are needed to see this picture.
QuickTime™ and aPhoto - JPEG decompressor
are needed to see this picture.
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, Nicotine and Tobacco Research, 2006; 8: 87-97 and 2009 11: 1025-1034.
6-month quit rates:
Study 1 6.3%
Study 2 (S) 5.6%
Study 3 13.5%
Study 4 (S) 26.0%
Study 5 (E/S; 80% fu)Study 5 (E/S; 80% fu) 20% at 1 yr20% at 1 yr
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
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
Breast Cancer Risk PerceptionKim S, Arch Intern Med 2008; 168: 728-734
WhiteWhite African African AmericanAmerican
LatinaLatina AsianAsian
No riskNo risk 22 77 1010 4848
Very low riskVery low risk 2727 2424 2020 1818
Somewhat or Somewhat or low risklow risk
3535 2727 3333 2323
Moderate riskModerate risk 2727 2828 1919 88
High or very High or very high riskhigh risk
88 1414 1818 33
Odds Ratios of Correct/Incorrect Use of Odds Ratios of Correct/Incorrect Use of Wall of Women VisualsWall of Women Visuals
Variable Wall of 100 Women
Odds Ratio of Correct
Less than High school education
0.44 (0.25-0.78)
African American 0.30 (0.17-0.54)
Chinese 0.49 (0.27-0.89)
Latina 0.34 (0.19-0.61)
Numeracy Score 1.29 (1.18-1.41)
Intervention Design: ComponentsMessageFormat: 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 Example: Breast cancer mortality is higher for
African Americans than any other group
Language: Know the audience Literacy Language preference
Intervention Design: ComponentsMessage: 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 Design: ComponentsChannel
The mechanism by which the message is delivered
Interpersonal (physicians, friends, counselors) Group (classroom activities) Mass media channels (radio, print media) Interactive digital media (Web, Kiosk, games,
videos, email)
Intervention Design: ComponentsChannel
Ethnic media addresses relevant issues to the communities they serve
Access to technology varies by ethnic group
Familiarity with technology
Perceptions of the Internet may vary by ethnic group
Intervention Design: Components
Setting Places where the intervention can reach the
intended program Home School or work Community organization Support groups
Times when the audience members may be more attentive
Waiting room Places or situations in which they will find
the message more credible Medical centers, churches
Intervention Design: Pretesting Pretesting
Assess comprehensibility (language) Readability assessment
Determine personal relevance
Identify confusing, sensitive, or controversial elements
Assess attention Content of the intervention Test the protocols
Evaluation of InterventionsTypes of evaluation
Process evaluation The process of implementation and how
the intervention performed as it takes place.
Impact evaluation Immediate effects of the intervention
or short-term outcome: knowledge/attitudes
Outcome evaluation: assessment of events reflecting long-term effects
Evaluation Evaluation of interventions
addressing health disparities a) Interventions using cultural leverage:
Reactions, outcomes less robust Cultural Leverage: Interventions using culture to narrow racial disparities in health
care Fisher et al Med Care Res Rev 2007; 64 195S
b) Generic interventions addressing breast cancer disparities at the health care setting
Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority. Masi et al., Med Care Res Rev 2007; 64 195S
Screening Interventions Patient interventions (Masi et al., 2007)
Patient targeted screening trials Reminder letters Written educational materials Telephone calls Culturally tailored classroom instructions Videos
Effect of these interventions was 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
Health Disparities Interventions Breast cancer interventions
The majority of these interventions were implemented by nurses and lay personnel
Interventions using culturally specific patient navigators and community health workers were the most successful strategies
None of the studies addressed the extent to which cultural aspects of the intervention brought about the improvements in care
Going Beyond Describing Disparities by Race/Ethnicity
We all want interventions that workWe all want interventions that work Need to define mechanisms or pathways Need to define mechanisms or pathways
so we can target effortsso we can target efforts Basic research in development of Basic research in development of
intervention contentintervention content Optimal point of interventions not clear –Optimal point of interventions not clear –
community, patients, system, clinicianscommunity, patients, system, clinicians Continue to describe and monitor Continue to describe and monitor
disparities as natural historydisparities as natural history
Conclusions Interventions design and implementation
need to address cultural as well as 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 those less likely to adopt new technologies
Need to do rigorous studies that assess outcome in studies that use cultural leverage