Gina Netto

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.

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.

Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study

Objectives The presence and extent of mental health inequalities in Scotland is unclear. We investigated ethnic variations in psychiatric hospitalisations and compulsory treatment in relation to socioeconomic indicators. Design In a retrospective cohort study design, using data linkage methods, we examined ethnic variations in psychiatric [any psychiatric, mood (affective), and psychotic disorders) hospitalisations and use of the Mental Health (Care and Treatment) (Scotland) Act 2003 (Emergency Detentions (ED), Short-Term Detentions (STD) and Compulsory Treatment Orders (CTO)] using age (and sex for compulsory treatment), car ownership, and housing tenure adjusted risk ratios (RR). 95% CIs for the data below exclude the reference White Scottish group value (100). Results Compared to the White Scottish population, Other White British men and women had lower hospitalisation from any psychiatric disorder (RR = 77.8, 95% CI: 71.0–85.2 and 85.8, 95% CI: 79.3–92.9), mood disorder (91.2, 95% CI: 86.9–95.8 and 83.6, 95% CI: 75.1–93.1), psychotic disorder (67.1, 95% CI: 59.9–75.2 and 78.5, 95% CI: 67.6–91.1), CTO (84.6, 95% CI: 72.4–98.9) and STD (88.2, 95% CI: 78.6–99.0). Any Mixed Background women had higher hospitalisation from any psychiatric disorder (137.2, 95% CI: 110.9–169.6) and men and women had a higher risk of psychotic disorder (200.6, 95% CI: 105.7–380.7 and 175.5, 95% CI: 102.3–301.2), CTO (263.0, 95% CI: 105.4–656.3), ED (245.6, 95% CI: 141.6–426.1) and STD (311.7, 95% CI: 190.2–510.7). Indian women had lower risk of any psychiatric disorder (43.2, 95% CI: 28.0–66.7). Pakistani men had lower risk of any psychiatric disorder (78.7, 95% CI: 69.3–89.3), and higher risk of mood disorders (117.5, 95% CI: 100.2–137.9). Pakistani women had similar risk of any psychiatric and mood disorder however, a twofold excess risk of psychotic disorder (227.3, 95% CI: 195.8–263.8). Risk of STD was higher in South Asians (136.9, 95% CI: 109.0–171.9). Chinese men and women had the lowest risk of hospitalisation for any psychiatric disorder (35.3, 95% CI: 23.2–53.7 and 44.5, 95% CI: 30.3–65.5) and mood disorder (51.5, 95% CI: 31.0–85.4 and 47.5, 95% CI: 23.2–97.4) but not psychotic disorders and higher risk for CTO (181.4, 95% CI: 121.0–271.0). African women had higher risk of any psychiatric disorder (139.4, 95% CI: 119.0–163.2). African men and women had the highest risk for psychotic disorders (230.8, 95% CI: 177.8–299.5 and 240.7, 95% CI: 163.8–353.9) and were also overrepresented in STD (214.3, 95% CI: 122.4–375.0) and CTO (486.6, 95% CI: 231.9–1021.1). Differences in hospitalisations were not fully attenuated when adjusted for car ownership and housing tenure and the effect of these adjustments varied by ethnic group. Conclusion Our data show disparate patterns of psychiatric hospitalisations by ethnic group in Scotland providing new observations concerning the mental health care experience of Chinese, Mixed background and White subgroups not fully explained by socioeconomic indicators. For South Asian and Chinese groups in particular, our data indicate under and late utilisation of mental health services. These data call for monitoring and review of services.

Identity Negotiation, Pathways to Housing and “Place”: The Experience of Refugees in Glasgow

Abstract The links between how individuals construct and negotiate identity as they navigate their way through the housing system and “place” have, to date, not been explicitly articulated. Yet, greater understanding of such links is important given the significance of location of housing in decision‐making processes and the often close relationship between “who we are” and “where we are”. The site of the current study is the city of Glasgow, one of the main sites in the UK for the government’s policy of “no‐choice” dispersal. Based on empirical data from individual interviews with 32 refugees and a sample of housing and other service providers, this paper explores the usefulness of the housing pathways approach to understanding the experiences of refugees in this city. It reveals that the housing pathways approach has much to offer as an analytical tool for illuminating the specific nature of refugees’ contact with, and progression through, the housing system and their changing identity/identities. More explicit links with “place” within the framework as the site for negotiated identity are important for understanding whether or not refugees choose to stay in the city or move on, and their negotiation of identity in the longer term.

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.

Vulnerability to Homelessness, Use of Services and Homelessness Prevention in Black and Minority Ethnic Communities

Despite the high prominence of homelessness on the housing policy agenda and evidence that a disproportionate number of people affected by homelessness come from black and minority ethnic (BME) communities, little is known about patterns of access and use of homelessness services in these communities. This paper seeks to fill the gap, by drawing on qualitative and quantitative research recently conducted in Scotland, and relevant literature. First, it considers some of the major factors that contribute to homelessness in black and minority ethnic communities as a basis for considering the level and type of support needed. Second, it examines the extent to which people affected by homelessness are able to draw on informal support. Third, the use of homelessness services is examined, including their accessibility and appropriateness for people from BME communities. The implications of the study for developing culturally sensitive homelessness policies and strategies are considered, including (a) the need to recognise and respond to specific vulnerabilities and varying forms of homelessness between and within communities; (b) the need for mainstream and specialist BME service provision and multi-agency working; (c) the case for culturally sensitive allocation policies, including the potential afforded by choice-based allocations and common housing registers; and (d) mechanisms for providing culturally responsive services to diverse communities, particularly where they are present in small numbers. The paper concludes by considering the contribution of the present study to theories of homelessness.

Strangers in the City: Addressing Challenges to the Protection, Housing and Settlement of Refugees

Abstract An increasing proportion of refugees worldwide now live in urban spaces, where their rights to adequate shelter, education and employment opportunities must be considered. In the European Union, a number of countries have tightened their immigration policies and adopted dispersal schemes which disperse refugees to urban environments. However, little is known about the circumstances of refugees once they have moved into permanent accommodation in these cities, how they cope and whether they stay or move on. This paper explores the impact of dispersing refugees to urban areas by drawing on a case study of refugees living in Glasgow, a major dispersal site for refugees in the UK. It reveals the diversity and complexity of the unique challenges that refugees face, including within the home and the neighbourhood. Four strands of policy implications flow from this: the need to facilitate refugee identification in urban areas; the importance of ensuring protection from racial harassment; the need for diversified approaches towards tenancy sustainment and the difficulty of predicting the impact of ‘no-choice’ dispersal policies.

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.

Creating a suitable space: A qualitative study of the cultural sensitivity of counselling provision in the voluntary sector in the UK

Background: Despite the rapid expansion of counselling services in the UK, the take-up of the service by people from minority ethnic backgrounds, including Asian people, is low. Aims: To assess the accessibility and appropriateness of counselling service provision in the UK for Asian people. Methods: Thirty-eight Asian people (19 clients and 19 non-clients) were interviewed on their perceptions and preferences for counselling services. The perspectives of clients and non-clients were compared with each other and those of representatives of 13 counselling agencies including those which served primarily Asian and other minority ethnic groups and those which served the general population. Results: Both clients and non-clients generally viewed counselling provision positively. However, some of their specific needs and preferences related to understanding the nature of the service, choice of counsellor and language of counselling were currently unmet by both mainstream and minority ethnic agencies. Conclusion: The current compartmentalization of counselling services does not acknowledge the considerable heterogeneity of Asian people. While in the short term, minority ethnic agencies play a crucial role in filling the gaps left by mainstream services, in the long term, good practice must lie in culturally sensitive counselling provision for all. Declaration of interest: The study was funded by the Joseph Rowntree Foundation.