Jj Liu

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.

MODIFYING HEALTH PROMOTION INTERVENTIONS FOR ETHNIC MINORITY GROUPS: SYSTEMATIC OVERVIEW OF GUIDELINES AND REVIEWS

Background Some UK ethnic minority groups experience disproportionate levels of morbidity and mortality when compared with the majority White population. For these populations, access to and use of health promotion interventions may be limited. Adaptation of smoking cessation, physical activity and nutrition interventions of proven effectiveness for the majority population could represent an efficient strategy for reducing persistent health inequalities when adapted for minority ethnic populations. Objectives To identify the high-level evidence for health promotion interventions which have proven effectiveness for the general population and construct a framework of effective interventions, including any recommendations relating to ethnic minority populations. Design A systematic overview was conducted with two reviewers independently searching and identifying guidelines and systematic reviews of interventions for smoking cessation, improving nutrition and physical activity. SIGN, NICE and Clinical Evidence databases were searched for relevant guidelines. Cochrane Library, Campbell Collection, HTA reviews and DARE databases were searched for systematic reviews. Data on the effectiveness of interventions were extracted. Results 19 guidelines were identified as relevant. 2399 systematic review records were identified and assessed for eligibility. 187 systematic reviews were included in the final analysis. The guidelines revealed a large evidence base for smoking cessation interventions, but highlighted major gaps in relation to how best to increase physical activity and improve nutrition. There was little advice in these guidelines on how to adapt interventions to meet the needs of ethnic minority populations. The 187 systematic reviews were screened to identify any additional effective interventions not included in the guidelines. All effective, evidence-based interventions have been compiled into a summary framework. The 187 systematic reviews were also subjected to a detailed assessment of the population composition to determine whether any subgroup analysis for ethnic minority groups was undertaken. Approximately half of the reviews reported the inclusion of ethnic minority groups; however, no reviews conducted subgroup analyses according to ethnicity and ethnic-specific recommendations were scarce. Conclusions The evidence base reviewed provides specific guidance on effective interventions for smoking cessation, but generic advice for increasing physical activity and improving nutrition. Identification of the range of evidence-based interventions for these three areas has led to the development of a summary framework that can be utilised for health promotion. Interventions already found to be effective in the majority population are, if appropriately adapted, likely to prove effective in minority ethnic populations. This work will advance current guidance on how to approach adaptation.

MODIFYING HEALTH PROMOTION INTERVENTIONS FOR ETHNIC MINORITY GROUPS: SYSTEMATIC REVIEW OF EMPIRICAL EVIDENCE

Background Health promotion interventions have proved to be cost-effective strategies to reduce morbidity and mortality associated with smoking, physical inactivity and poor diet in the general population. Some ethnic minority groups are disproportionately affected by these lifestyle factors, and existing evidence suggests that adapting evidence-based health promotion interventions for these populations may prove to be an effective strategy to tackle health inequalities. Objectives To identify health promotion interventions for smoking cessation, increasing physical activity and improving nutrition which have been adapted for African-Caribbean, South Asian and Chinese-origin populations and to document how this has been achieved and with what effect. Design A systematic review was conducted with two reviewers independently searching, identifying, extracting and critically appraising empirical studies of adapted interventions. The databases searched include MEDLINE, EMBASE, ASSIA, Psycinfo, CINAHL, BIOSIS, Cochrane, ISI Web of Science, Lilacs, Campbell and SCEH. Results In total, 48 740 records were identified. 95 empirical studies were identified as relevant and included in the analysis. The majority of adapted intervention studies took place in the USA, conducted with African-Caribbean origin populations and these predominantly involved women. All studies conducted with Chinese-origin populations took place in the USA while the majority of studies with South Asian-origin populations were conducted in the UK. Multi-component interventions targeting physical activity and nutrition were the most common followed by smoking cessation interventions. Interventions utilised a variety of adapted methods, resources and/or settings. The components of the adaptation process identified include methods such as ethnically matching programme facilitators; subsidising gym memberships and promoting low-cost alternatives to usual exercise options. Resources include culturally targeting materials (eg, using ethnic actors in videos and including photos of foods commonly consumed by the population in promotional material); utilising existing community resources (eg, religious leaders) and accommodating for differing linguistic and language competencies. Settings include holding interventions in familiar locations and utilising culturally appropriate scenarios to elicit behaviour change. Conclusions A large body of evidence exists for adapted interventions. Identification of the components involved in the adaptation process for ethnic minority populations is a critical step for building on existing adaptation principles. Furthermore, this study will enable the development of a framework to guide the adaptation of mainstream evidence-based guidelines to be salient for different populations and contexts.