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