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

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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