Developing, Implementing and Evaluating Interventions to Reduce Health Disparities

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Developing, Implementing and Evaluating
Interventions to Reduce Health Disparities

• Eliseo J. Pérez-Stable, MD
• Health Disparities Research Methods
• EPI 222
• May 31, 2012

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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
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Phases of Intervention Research

• I. Hypothesis development
• II. Methods development
• III. Controlled intervention trials
• IV Defined population studies
• V Demonstration / implementation
• Nationwide prevention and health services
  programs

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Categories of Interventions

• Lifestyle 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
• Health-related behaviors and outcomes screening
  tests, medication adherence, control of chronic
  disease, birth-weight, falls prevention,
  vaccinations
• Health Services Reminders, flow-charts
• Medications Differential effects by sex, race,

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The Intervention Cycle
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Five-Year Relative Survival Rates by Race and
Stage, US, 1975-1979 to 1992-1999
Source Ghafoor, Jemal et al, 2003
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Five-Year Relative Survival Rates by Race and
Stage United States (SEER), 1975-1979 to 1992-1999
Source Ghafoor, Jemal et al, 2003
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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

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Identifying Intervention Components

• Qualitative methodology focus groups,
  semi-structured interviews, key informants
• Barriers 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

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Intervention Design Theory

• Selection 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)

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Intervention 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

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Cultural 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
  practicesinvolve community members
• Implements interventions by professionals from
  the targeted groups

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Culturally-Tailored Interventions
Generic interventions with modifications
Cultural targeting
More Individually Tailored
More Generic
Identification of common elements across cultures
Individual cultural tailoring
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Intervention Design

• Development
• Review existing materials
• Develop own materials
• Basic components
• Source
• Message
• Channel
• Setting

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Subjective Culture of Smoking

• 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

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Cultural Tailoring of Cessation Messages for
Latinos 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?

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Multivariate Model Results for Latino Ethnicity
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
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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?

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Guia Para Dejar de Fumar

• Developed in 1987, revised 3 times in Spanish,
  color photos, low literacy
• Free on NCI Planet web site, updated
  pharmacological information
• Evaluation from post implementation showing
  acceptance and cessation-8.4
• Used as intervention component in community
  studies
• Culturally and linguistically tailored 6th grade
  reading level

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Smoking Prevalence in SF Latinos, Age 18-64,
1986-89
1986 1987 1988 1989
(n) (1659) (2053) (1965) (1989)
Men 34.5 27.0 27.8 24.4
Women 17.1 17.1 16.4 12.2
Low Acc 24.8 20.3 18.9 15.3
Hi Acc 24.1 22.6 25.0 21.4
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Tomando Control 2

• http//stopsmoking.ucsf.edu
• Randomized Smoking Cessation Trial on the Web

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Intent-to-Treat 7-day Abstinence Rates of
Internet InterventionMuñoz RF, 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) 20 at 1 yr

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Cancer 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

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Misconceptions About Cancer Did Not Predict
Screening Behavior

• Latinos more likely to have attitudes and
  beliefs that may lead to less screening
• Fatalismo reflected in cancer Gods
  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

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Communication of Risk Study

• 199 women, 65, 4 race/ethnic groups45 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 (OR1.25 per year CI1.09-1.44)
  predictive of ending screening
• Sawaya G, et al. Am J Obstetrics Gynecology 2009
  200 40e1-40e7

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Breast Cancer Risk PerceptionKim S, et al, Arch
Intern Med 2008 168 728-734
White African American Latina Asian
No risk 2 7 10 48
Very low risk 27 24 20 18
Somewhat or low risk 35 27 33 23
Moderate risk 27 28 19 8
High or very high risk 8 14 18 3
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CRISP Study Odds Ratios of Correct/Incorrect Use
of Wall 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)
Wong S, et al. Patient Education Counseling 2012
Jan 11 Epub
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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

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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
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Intervention Design Components

• Message
• Format 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)

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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)

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Intervention Channels

• The mechanism by which the message is delivered
• Interpersonal physicians, friends, counselors,
  individual attention
• Group classroom activities, web
• Mass media channels radio, print media,
  Internet, mobile technology
• Interactive digital media Web, Kiosk, games,
  videos, tablet

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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

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Intervention Design 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

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Intervention Design Pretesting

• Assess comprehensibility (language)
• Readability assessment
• Determine personal relevance
• Identify confusing, sensitive, or controversial
  elements
• Assess attention
• Content of the intervention
• Test the protocols

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Evaluation of Interventions

• Types 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

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Evaluation

• Evaluation of interventions addressing health
  disparities
• 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
• 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

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Screening Interventions

• Patient interventions (Masi et al., 2007)
• Patient targeted screening trials
• Reminder letters
• Written educational materials
• Telephone calls
• Culturally tailored classes
• Videos
• Effects were not uniform among all groups
• Studies among low-acculturated Latinas
  demonstrated a positive effect of culturally
  tailored interventions

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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

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Housing Vouchers Improve Health

• HUD randomly assigned 4498 women living with
  children in public housing in high poverty area
  (gt40) from 1994 to 1998
• Rent-subsidy housing vouchers to be used to move
  to low-poverty census tract (10)
• Traditional housing vouchersno 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 3651509-19

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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
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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

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Going Beyond Describing Disparities by
Race/Ethnicity

• We all want interventions that work
• Need to define mechanisms or pathways so we can
  target efforts
• Basic research in development of intervention
  content
• Optimal point of interventions community,
  patients, system, clinicians
• Continue to describe and monitor disparities as
  natural history