E Davidson

Adapting health promotion interventions to meet the needs of ethnic minority groups: mixed-methods evidence synthesis

BACKGROUND There is now a considerable body of evidence revealing that a number of ethnic minority groups in the UK and other economically developed countries experience disproportionate levels of morbidity and mortality compared with the majority white European-origin population. Across these countries, health-promoting approaches are increasingly viewed as the long-term strategies most likely to prove clinically effective and cost-effective for preventing disease and improving health outcomes in those with established disease. OBJECTIVES To identify, appraise and interpret research on the approaches employed to maximise the cross-cultural appropriateness and effectiveness of health promotion interventions for smoking cessation, increasing physical activity and improving healthy eating for African-, Chinese- and South Asian-origin populations. DATA SOURCES Two national conferences; seven databases of UK guidelines and international systematic reviews of health promotion interventions aimed at the general population, including the Clinical Evidence, National Institute for Health and Clinical Excellence and Scottish Intercollegiate Guidelines Network databases (1950-2009); 11 databases of research on adapted health promotion interventions for ethnic minority populations, including BIOSIS, EMBASE and MEDLINE (1950-2009); and in-depth qualitative interviews with a purposive sample of researchers and health promoters. REVIEW METHODS Theoretically based, mixed-methods, phased programme of research that involved user engagement, systematic reviews and qualitative interviews, which were integrated through a realist synthesis. Following a launch conference, two reviewers independently identified and extracted data from guidelines and systematic reviews on the effectiveness of interventions for the general population and any guidance offered in relation to how to interpret this evidence for ethnic minority populations. Data were thematically analysed. Reviewers then independently identified and critically appraised studies of adapted interventions and summarised data to assess feasibility, acceptability, equity, clinical effectiveness and cost-effectiveness. Interviews were transcribed, coded and thematically analysed. The quantitative and qualitative data were then synthesised using a realist framework to understand better how adapted interventions work and to assess implementation considerations and prioritise future research. Our preliminary findings were refined through discussion and debate at an end-of-study national user engagement conference. RESULTS Initial user engagement emphasised the importance of extending this work beyond individual-centred behavioural interventions to also include examination of community- and ecological-level interventions; however, individual-centred behavioural approaches dominated the 15 relevant guidelines and 111 systematic reviews we identified. The most consistent evidence of effectiveness was for pharmacological interventions for smoking cessation. This body of work, however, provided scant evidence on the effectiveness of these interventions for ethnic minority groups. We identified 173 reports of adapted health promotion interventions, the majority of which focused on US-based African Americans. This body of evidence was used to develop a 46-item Typology of Adaptation and a Programme Theory of Adapted Health Promotion Interventions. Only nine empirical studies directly compared the effectiveness of culturally adapted interventions with standard health promotion interventions, these failing to yield any consistent evidence; no studies reported on cost-effectiveness. The 26 qualitative interviews highlighted the need to extend thinking on ethnicity from conventional dimensions to more contextual considerations. The realist synthesis enabled the production of a decision-making tool (RESET) to support future research. LIMITATIONS The lack of robust evidence of effectiveness for physical activity and healthy-eating interventions in the general population identified at the outset limited the comparative synthesis work we could undertake in the latter phases. Furthermore, the majority of studies undertaking an adapted intervention were conducted within African American populations; this raises important questions about the generalisability of findings to, for example, a UK context and other ethnic minority groups. Lastly, given our focus on three health areas and three populations, we have inevitably excluded many studies of adapted interventions for other health topics and other ethnic minority populations. CONCLUSIONS There is currently a lack of evidence on how best to deliver smoking cessation, physical activity and healthy eating-related health promotion interventions to ethnic minority populations. Although culturally adapting interventions can increase salience, acceptability and uptake, there is as yet insufficient evidence on the clinical effectiveness or cost-effectiveness of these adapted approaches. More head-to-head comparisons of adapted compared with standard interventions are warranted. The Typology of Adaptation, Programme Theory of Adapted Health Promotion Interventions and RESET tool should help researchers to develop more considered approaches to adapting interventions than has hitherto been the case. FUNDING The National Institute for Health Research Health Technology Assessment programme.

The impact of ethnicity on asthma care

Asthma is a significant global health problem. Asthma prevalence, its related health outcomes, and associated healthcare utilisation, vary by population group both across and within nations. Evidence of ethnic variations in the prevalence and outcomes of asthma within nations have been well documented. This review examines the impact of ethnicity on asthma, with a focus on the literature from the UK and the USA. Explanations for the unequal burden of disease experienced by ethnic minority groups include: their health beliefs, attitudes, experiences and behaviours; the problem of poor health literacy, which tends to compound the challenges inherent in cross-cultural communication; concerns about the quality of care; and the relatively poor socio-economic position of minority ethnic groups and how this impacts on the wider determinants of health. We conclude by suggesting research priorities for asthma and ethnicity, along with practical actions within a collaborative care model.

Behavior Change Interventions to Improve the Health of Racial and Ethnic Minority Populations: A Tool Kit of Adaptation Approaches

CONTEXT Adapting behavior change interventions to meet the needs of racial and ethnic minority populations has the potential to enhance their effectiveness in the target populations. But because there is little guidance on how best to undertake these adaptations, work in this field has proceeded without any firm foundations. In this article, we present our Tool Kit of Adaptation Approaches as a framework for policymakers, practitioners, and researchers interested in delivering behavior change interventions to ethnically diverse, underserved populations in the United Kingdom. METHODS We undertook a mixed-method program of research on interventions for smoking cessation, increasing physical activity, and promoting healthy eating that had been adapted to improve salience and acceptability for African-, Chinese-, and South Asian-origin minority populations. This program included a systematic review (reported using PRISMA criteria), qualitative interviews, and a realist synthesis of data. FINDINGS We compiled a richly informative data set of 161 publications and twenty-six interviews detailing the adaptation of behavior change interventions and the contexts in which they were undertaken. On the basis of these data, we developed our Tool Kit of Adaptation Approaches, which contains (1) a forty-six-item Typology of Adaptation Approaches; (2) a Pathway to Adaptation, which shows how to use the Typology to create a generic behavior change intervention; and (3) RESET, a decision tool that provides practical guidance on which adaptations to use in different contexts. CONCLUSIONS Our Tool Kit of Adaptation Approaches provides the first evidence-derived suite of materials to support the development, design, implementation, and reporting of health behavior change interventions for minority groups. The Tool Kit now needs prospective, empirical evaluation in a range of intervention and population settings.

Smoking cessation interventions for ethnic minority groups - A systematic review of adapted interventions

OBJECTIVE Existing smoking cessation interventions tend to be under utilized by ethnic minority groups. We sought to identify smoking cessation interventions that have been adapted to meet the needs of African-, Chinese- and South Asian-origin populations, to increase understanding of the approaches used to promote behavior change, to assess their acceptability to the target populations, and to evaluate their effectiveness. METHODS Two reviewers independently searched for, identified, critically appraised and extracted data from studies identified from 11 databases (January 1950-April 2013). Study quality was assessed using validated instruments (EPHPP and STROBE). Adaptations were independently coded using an established typology, and findings descriptively summarized and thematically synthesized. RESULTS 23 studies described interventions adapted for African-Americans, and five for Chinese-origin populations. No intervention adapted for South-Asian populations was identified. Six studies directly compared a culturally adapted versus a non-adapted intervention. Adapted interventions were more acceptable to ethnic minority groups, but this did not translate into improvements in smoking cessation outcomes. CONCLUSIONS Given the evidence of greater acceptability of adapted interventions, it may be ethically preferable to use these. There is, however, no clear evidence of the effectiveness of adapted interventions in promoting smoking cessation in ethnic minority groups.

Consideration of ethnicity in guidelines and systematic reviews promoting lifestyle interventions: a thematic analysis

BACKGROUND There is a growing body of evidence supporting lifestyle interventions for the prevention of chronic disease. However, it is unclear to what extent these evidence-derived recommendations are applicable to ethnic minority populations. We sought to assess the degree of consideration of ethnicity in systematic reviews and guidelines for lifestyle interventions. METHODS Two reviewers systematically searched seven databases to identify systematic reviews (n = 111) and UK evidence-based guidelines (n = 15) on smoking cessation, increasing physical activity and promoting healthy diet, which were then scrutinized for ethnicity-related considerations. Evidence statements were independently extracted and thematically analysed. RESULTS Forty-one of 111 (37%) systematic reviews and 12 of 15 (80%) guidelines provided an evidence statement relating to ethnicity; however, these were often cursory and focused mainly on the need for better evidence. Five major themes emerged: (i) acknowledging the importance of diversity and how risk factors vary by ethnicity; (ii) noting evidence gaps in the effectiveness and cost-effectiveness of interventions for ethnic minorities; (iii) observing differential effects of interventions where these have been trialled with ethnic minority populations; (iv) suggesting adaptation of interventions for ethnic minority groups; (v) proposing improvements in research on interventions involving ethnic minority populations. CONCLUSIONS Despite increasing recognition of the challenges posed by ethnic health inequalities, there remains a lack of guidance on the extent to which generic recommendations are applicable to, and how best to promote lifestyle changes in, ethnic minority populations. These important evidence gaps need to be bridged and tools developed to ensure that equity and population context is appropriately considered within evidence syntheses.

Integrating Telehealth Care-Generated Data With the Family Practice Electronic Medical Record: Qualitative Exploration of the Views of Primary Care Staff

Background Telehealth care is increasingly being employed in the management of long-term illness. Current systems are largely managed via “stand-alone” websites, which require additional log-ons for clinicians to view their patients’ symptom records and physiological measurements leading to frustrating delays and sometimes failure to engage with the record. However, there are challenges to the full integration of patient-acquired data into family physicians’ electronic medical records (EMR) in terms of reliability, how such data can best be summarized and presented to avoid overload to the clinicians, and how clarity of responsibility is managed when multiple agencies are involved. Objective We aimed to explore the views of primary care clinicians on the acceptability, clinical utility, and, in particular, the benefits and risks of integrating patient-generated telehealth care data into the family practice EMR and to explore how these data should be summarized and presented in order to facilitate use in routine care. Methods In our qualitative study, we carried out semi-structured interviews with clinicians with experience of and naïve to telehealth care following demonstration of pilot software, which illustrated various methods by which data could be incorporated into the EMR. Results We interviewed 20 clinicians and found 2 overarching themes of “workload” and “safety”. Although clinicians were largely positive about integrating telehealth care data into the EMR, they were concerned about the potential increased workload and safety issues, particularly in respect to error due to data overload. They suggested these issues could be mitigated by good system design that summarized and presented data such that they facilitated seamless integration with clinicians’ current routine processes for managing data flows, and ensured clear lines of communication and responsibility between multiple professionals involved in patients’ care. Conclusions Family physicians and their teams are likely to be receptive to and see the benefits of integrating telehealth-generated data into the EMR. Our study identified some of the key challenges that must be overcome to facilitate integration of telehealth care data. This work particularly underlines the importance of actively engaging with clinicians to ensure that systems are designed that align well with existing practice data-flow management systems and facilitate safe multiprofessional patient care.

Adapting health promotion interventions for ethnic minority groups: a qualitative study

Adaptation of health interventions has garnered international support across academic disciplines and among various health organizations. Through semi-structured interviews, we sought to explore and understand the perspectives of 26 health researchers and promoters located in the USA, UK, Australia, New Zealand and Norway, working with ethnic minority populations, specifically African-, South Asian- and Chinese-origin populations in the areas of smoking cessation, increasing physical activity and healthy eating, to better understand how adaptation works in practice. We drew on the concepts of intersectionality, representation and context from feminist, sociology and human geography literature, respectively, to help us understand how adaptations for ethnic groups approach the variable of ethnicity. Findings include (i) the intersections of ethnicity and demographic variables such as age and gender highlight the different ways in which people interact, interpret and participate in adapted interventions; (ii) the representational elements of ethnicity such as ancestry or religion are more complexly lived than they are defined in adapted interventions and (iii) the contextual experiences surrounding ethnicity considerations shape the receptivity, durability and continuity of adapted interventions. In conclusion, leveraging the experience and expertise of health researchers and promoters in light of three social science concepts has deepened our understanding of how adaptation works in principle and in practice for ethnic minority populations.

Achieving Ethnic Diversity in Trial Recruitment

Research investigating the relationship between ethnicity and health has revealed that there are considerable and persistent health inequalities experienced by ethnic minority populations. There is general consensus among policymakers, researchers and community members that research should aim to help reduce disease burden and redress such health inequalities. Increasing the diversity of participants enrolled into clinical trials is one way to help achieve these aims. Increased funding, motivation and interest have catalyzed research in this area, resulting in its emergence as a field of enquiry in its own right.Many practical challenges and limitations, however, remain; foremost is that it remains unclear as to what are the most effective strategies for recruiting and retaining ethnic minority populations in clinical trials. Working towards meaningful participation requires a brief consideration of the conceptualizations underpinning this field of study. The prioritization of ethnicity above other important contributors to health, such as socioeconomic status, and the focus on differences also necessitates critical examination. Nonetheless, the gains of enrolling more diverse populations can strengthen our confidence in the generalizability of findings from experimental studies. There are obvious barriers to recruitment that are, we argue, present as a consequence of interactions between multiple players involved in the research process. This means that funding bodies, researchers and community members are implicated as both the problem and the solution. Thus, we believe that genuine improvements to representation of diverse populations in trials depend on their collaborative efforts. A priori definition of the targeted population and potential hypotheses, and the conduct of feasibility studies are important starting points. Ultimately, a diverse set of recruitment strategies should be used, some of which we outline in this article. A balance must be struck in terms of when and how to use population- and community-based recruitment methods, active and passive recruitment approaches and culturally sensitive strategies. Our belief is that meaningful inclusion and participation will occur as funding bodies, researchers and community members work together towards a shared goal of improving health outcomes for all sections of society.

Big data, qualitative style: a breadth-and-depth method for working with large amounts of secondary qualitative data

Archival storage of data sets from qualitative studies presents opportunities for combining small-scale data sets for reuse/secondary analysis. In this paper, we outline our approach to combining multiple qualitative data sets and explain why working with a corpus of ‘big qual’ data is a worthwhile endeavour. We present a new approach that iteratively combines recursive surface thematic mapping and in-depth interpretive work. Our breadth-and-depth method involves a series of steps: (1) surveying archived data sets to create a new assemblage of data; (2) recursive surface thematic mapping in dialogue with (3) preliminary ‘test pit’ analysis, remapping and repetition of preliminary analysis; and (4) in-depth analysis of the type that is familiar to most qualitative researchers. In so doing, we show how qualitative researchers can conduct ‘big qual’ analysis while retaining the distinctive order of knowledge about social processes that is the hallmark of rigorous qualitative research, with its integrity of attention to nuanced context and detail.

Developing and testing of a screening tool to predict people without IgE-mediated allergy: a quantitative analysis of the predictive value of a screening tool

BACKGROUND Consultations in primary care for allergies are common. It can be difficult to differentiate between IgE-mediated (atopic) symptoms - which respond to allergen-specific interventions - and those that are non-atopic, without performing objective tests that are largely unavailable in UK general practice. AIM To develop and test a screening tool that can accurately discriminate between atopic and non-atopic individuals. DESIGN AND SETTING A validation study that took place in 2012 in adult volunteers aged >16 years in Scotland. METHOD A questionnaire screening tool was developed using questions from a large cohort study and through consultation with experts. Participants answered the questions and had skin prick tests for four aeroallergens (house dust mite, cat, dog, and mixed grasses). Participants were classified as atopic if any average wheal diameter was ≥3 mm bigger than the negative control. Sensitivity, specificity, and positive and negative predictive values of individual and combinations of questions were calculated. RESULTS In all, 143 participants completed the questionnaire and underwent skin prick testing. Of these, 81 (56.6%) were atopic. Negative predictive values for the individual questions ranged from 48.2% (55 not atopic out of 114 negative answers) to 72.0% (18/25). An optimum combination of four questions was identified, in which a negative answer to all four questions was reported by 24 participants, 21 (87.5%) of whom were not atopic. CONCLUSION The authors have identified a set of questions that correctly predict negative skin prick tests to common aeroallergens 88% of the time. These may be useful to exclude patients who do not warrant further investigation and who can reliably be advised that allergen avoidance is neither necessary nor helpful.