The Science of Targeting and its Application in Health Care Lisa A. Cooper, MD, MPH April 8, 2010 Goal: To describe how we learn about group characteristics

The Science of Targeting and its Application in Health Care

Lisa A. Cooper, MD, MPH

April 8, 2010

Goal: To describe how we learn about group characteristics and develop skills that foster better delivery of health care

Objectives

1. Describe approaches to enhancing cultural sensitivity in health care

2. Provide examples of demographic, social, and cultural targeting in marketing messages and health care interventions

3. Identify effective strategies for demographic targeting that optimize positive images and minimize negative stereotypes and stigma

4. Explain how targeting and tailoring can be combined to acknowledge individual differences when designing population-level interventions

Targeting versus Tailoring

• Targeted interventions involve messages that are intended to reach population subgroups based on a specific set of shared characteristics

• Tailored interventions, involve messages that are intended to reach an individual based on specific characteristics of the individual as measured in a formal assessment process

Approaches to Enhancing Cultural Sensitivity in Health Care

• Early programs: cross-cultural medicine, cultural sensitivity, trans-cultural nursing, and multicultural counseling

• Focused on those “whose health beliefs may be at variance with biomedical models” – e.g. groups with limited English proficiency, non-Western

cultures, etc.

• Original approaches called for awareness and respect for different traditions, but recognized– detailed knowledge about all cultures was impractical– viewing patients as members of ethnic/cultural groups

might lead to stereotyping

Evolution of Cultural CompetenceEarly models recognized the need for “generic” attitudes not specific to a particular culture:

1) respecting the legitimacy of patients’ health beliefs 2) shifting from a paradigm of viewing patients’ complaints

as stemming from a disease to that of an illness occurring within a biopsychosocial context

3) eliciting patients’ explanatory model of illness 4) explaining the clinician’s explanatory model of illness in

language accessible to patients5) negotiating an understanding within which a safe,

effective, and mutually agreeable treatment plan could be implemented

Berlin & Fowkes (1983); Kleinman et al. (1978); Leininger (1978)

Disparities move to forefront of national health agenda

1970 20071990

1985 DHHS Heckler Report on Black and Minority Health

Minority Health and Health Disparities Research and Education Act of 2000

Healthy People 2010

2003 IOM Report “Unequal Treatment” and first National Healthcare Disparities Report published

1972Tuskegee Syphilis Study becomes public

1980

Health Revitalization Act of 1993 establishes the Office of Research on Minority Health

2000 2010

Expansion of Cultural Competence

Early models (cross-cultural)

Newer models(Cultural Competence)

Populations Immigrants, refugees

All people of color, other disadvantaged groups

(those affected by health disparities)

Concepts Culture, Language

Culture, Language, Prejudice, Stereotyping, Social Determinants of Health

Scope Interpersonal interactions

Health Care Systems, Communities

Definitions of Cultural Competence

• Interpersonal Cultural Competence– The ability of individual health care professionals to

establish effective interpersonal and working relationships with patients (and each other) that supersede cultural differences1

• Health System Cultural Competence– The ability of health care providers and organizations to

understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter2

1Cooper & Roter, 2OMH 2001

Organizational and InterpersonalCultural Competence

Within Health Care Organizations: Ability of the health care organization to meet needs of diverse groups of patients:

Culturally Competent Health

Care Systems

Culturally Competent Health Care Interactions

Within Interpersonal Interactions: Ability of a provider to bridge cultural differences to build an effective relationship with a patient:

• Understands the meaning culture

• Is knowledgeable about different cultures

• Appreciates diversity• Is aware of health

disparities and discrimination affecting minority groups

• Effectively uses interpreter services when needed

• Diverse workforce reflecting patient population

• Facilities convenient to community

• Language assistance for patients with limited English proficiency

• Staff training regarding delivery of culturally and linguistically appropriate services

• Culturally appropriate health education materials

Saha S, Beach MC, Cooper LA. J Natl Med Assoc 2008;100: 1275-1285

Using Behavioral Models to Understand Ethnic Differences in Care-Seeking for Depression

Behavioral beliefs

Effectiveness

Medications

Counseling

Prayer

Perceived need

Value of outcome

External Variables

Demographics

Race, Ethnicity Gender, Age, Education

Illness variables

Treatment Experience

Social Support

Life Events

Internal Variables

Normative beliefs

Family would be disappointed

Attitudes toward behavior

Treatment acceptability

Subjective norms

Employer stigma Friend stigma

Behavioral Intention

Plans to seek help

Behavior

Seeks treatment

Modified from The Theory of Reasoned Action (Azjen, 1996)

Sample Comments Made by Patients in Depression Focus Groups

“I did pray a lot. I’m a Christian, and I would pray and pray and find verses of scripture.”

African-American male, age 30

Spirituality

Cooper-Patrick L et al, JGIM 1997;12:431-438


“And I didn’t want anyone to know that I was taking this prescription. I just didn’t

want to feel like I was crazy.”

African-American female, age 53

Stigma



“This guy [my doctor] was just a plain old nice guy, you know…he was very, very

sharp…I thought, whatever this guy tells me for the most part, if it sounds sensible, I’ll

give it a try.”

African American male, age 28

Patient-provider relationships



“If it’s gonna make me feel good, make me feel good right away so I can get up

and start doing what I want to do. I don’t want it to take a long time to kick in.”

female, age 41

Attributes of treatment: Medicines



“When you explain to me what the medicine’s going to do and what I can expect

from it, I feel much more comfortable.”

female, age 41

Attributes of treatment: Patient education


Most Important Aspects of Depression Care to Patients

1. Health provider interpersonal skills

2. Treatment effectiveness

3. Treatment problems

4. Patient education, information, and understanding

5. Intrinsic spirituality * (African Americans)

6. Financial access

7. Primary care provider recognition of depression

Cooper LA et al, Gen Hosp Psychiatry 2000;22:163-173

African Americans rate spirituality as more important in depression care

Cooper LA et al, Journal of General Internal Medicine 2001;16:634-638

All p-values <0.05

Views about depression differ among Whites, Blacks, and Hispanics

White Blacks Hispn=659 n=97 n=72

I believe I need treatment 68 70 68Medications are effective 91 69 84 †Medications are addictive 34 56 51 **Counseling is as effective as meds 50 57 74 **Counseling brings up bad feelings 50 71 71 **Prayer heals depression 67 93 67 †Socially embarrassed 24 24 33Family would be disappointed 16 15 22Prefer same ethnicity/race provider 14 25 13 *

*p<0.05, **p<0.01, †p<0.001 Cooper LA et al. Med Care 2003;41:479-489

Physicians engage in less depression talk and rapport-building with depressed African Americans

Ghods BK, Roter D, Ford DE, Larson S, Arbelaez J, Cooper LA. J Gen Intern Med 2008; 23:600-6

P=0.04 P=0.01

P=0.07

P=0.30

Questions to guide selection of tailored vs. targeted message strategy• Is there variability on the key determinants of depression

care-seeking?– Tailoring: high

– Targeted: high or low

• Are there mechanisms for gathering individual-level data from the target population?– Tailored: needed

– Targeted: not needed

• What is the level of awareness or understanding of the problem in the target population?– Tailored: high

– Targeted: high or low

Black and Blue: A culturally targeted videotape about depression

Sample comments made by patients in videotape focus group

Theme Sample Comments

Most effective parts of the videotape

“I think having real people with real problems was effective.”

Ways to improve the videotape

“It would have been more effective if maybe we had more specifics on what caused their depression, and how they got through it, and what treatment worked for them.”

Identification with people in the videotape

“Depression, in the younger fellow who talked, yes, everything he said hit home to me.”

Primm AB, Cabot D, Pettis J, Vu HT, Cooper LA. J Natl Med Assoc 2000;94:1007-1016



Race, ethnicity and cultural issues

“I’ve never really paid much attention to videos in the past because they mainly had Caucasians that I couldn’t really relate to, and to sit here and watch something with people who look like me, talk like me, and went through what I went through, seeing is believing that black people have gone through this.”

“A lot of reasons we [blacks] don’t seek out this help that we so desperately need, is because as African-American children, we’re taught to be strong-don’t let them see you cry. Then when you show up you don’t know what to say, “ I need help, can somebody help me?”



Stigma and stereotypes

“I was surprised to see so many men [in the video] because a lot of times [depression] is called the woman’s disease because men don’t really get upset ‘cause they have a strong backbone, so it was cool to see men going though it.”

Spirituality “The other thing [that was effective about the video] as the faith piece, other people who are of your faith that tell you, you don’t pray, you need to pray harder, that’s all you need to do. That’s not true.”

Agreement with statements about medical aspects of depression

Primm AB, Cabot D, Pettis J, Vu HT, Cooper LA. J Natl Med Assoc 2000;94:1007-1016

Agreement with statements about treatment effectiveness

Disagreement with statementsabout treatment problems

Disagreement with statements about spirituality

Disagreement withstatements about stigma

Strategies for effective targeting• Optimize positive images

– Feature African Americans (regular and successful people) who have experienced depression and gotten better

• Dispel misconceptions– Discuss common myths and counteract with information

• Avoid negative stereotypes– Depression is a medical illness, not a character weakness or

something to be ashamed of

• Reduce stigma– Use public figures as role models

– Encourage relatives and friends of depressed individuals to try to understand the illness and be supportive

• Design: Cluster randomized trial• Population: 27 primary care providers and 132 African

American patients with depression • Setting: 10 urban, community-based clinics in

Baltimore, MD and Wilmington, DE• Interventions:

– Standard quality improvement program– Patient-centered, culturally targeted program

• Outcomes: depression resolution, guideline-concordant care, and patient ratings of care at 6 & 12 mo follow up

Blacks Receiving Interventions for Depression and Gaining Empowerment

Supported by the Agency for Healthcare Research and QualityCooper LA, Ford DE, Ghods BK, et al. Implementation Science. 2010; 5(1):18

Provider Recruitment

Patient-Centered Intervention

ProvidersN=15

*DCM contacts for active follow-up up to 12 months

Standard Intervention

ProvidersN=15

Standard Intervention

Patients*N=125

Patient-CenteredIntervention

Patients*N=125

Patient Recruitment

Bridge Study Primary Care Clinician Intervention Features

Intervention Standard Intervention

Patient-Centered

Intervention

Two academic detailing visits (CME credit)

X X

Psychiatric consultation liaison support

X X

Communication skills on interactive CD-ROM

X

Culture-specific information

X

Examples of Clinician Goals

• Improve recognition• Evaluate associated conditions• Assess suicidal ideation• Change usual antidepressant• Identify patients’ cultural

beliefs• Elicit patients’ preferences

Functions of the Medical Interview

• Data-gathering

• Patient education and counseling

• Rapport-building

• Facilitation and patient activation

Lipkin, Putnam, & Lazare, 1995

Interactive CD-ROM

Bridge Study Patient InterventionsIntervention Standard

InterventionPatient-Centered

Intervention

Needs Assessment X

Patient Centered Needs Assessment X

Education and Activation X X

Social support/informal counseling X X

Standard education materials X

Culturally targeted education materials X

Black Mental Health Alliance List X

Cultural information packet for MH Providers

X

The standard needs assessment is generic and disease-oriented

• Depressive symptoms

• Associated conditions

• Functional Status/Activities affected

• Stressors

• Social Support

• Treatment preferences

Standard InterventionPatient Education Materials

• Brochure

• Book

• DVD

The patient-centered needs assessment combines targeted and

tailored approaches• Meaning of illness from patient perspective• Perceptions of racial discrimination • Literacy and language concerns• Importance of spirituality in coping and care• Specific treatment concerns regarding

antidepressants or counseling• Financial concerns• Role of stigma• Relationships with health professionals

Patient-Centered Intervention Patient Education Materials

• Brochure

• Book

• Videotape

• Prayer card*

• Bridge Study calendar

*only if patient is spiritually oriented and/or receptive

Patients rated the patient-centered depression care manager as more helpful

*p<0.05

More patients read books and brochures -- half watched videos

Most patients felt information presented was helpful

Most patients could identify with messages in the materials

More family members and close friends used targeted materials

Conclusions• Cultural targeting has been identified as a

potential strategy for overcoming disparities in health care

• Behavioral models can be used to identify appropriate content and strategies for targeting in healthcare interventions and materials

• Gathering data/input from targeted groups can enhance acceptability and uptake of interventions

• Combining targeting and tailoring improves perceived relevance and minimizes stereotyping

Discussion Points

• What is the added benefit of targeting over generic approaches for particular behaviors?

• For which groups is targeting most effective?

• How much customization of messaging is needed to achieve relevance?

• When is customization perceived as negative?

• Should customization be implicit or explicit?

• What are the pros and cons of being more inclusive versus more targeted in one’s approach?

Documents

The Science of Targeting and its Application in Health Care Lisa A. Cooper, MD, MPH April 8, 2010 Goal: To describe how we learn about group characteristics