Cultural Sensitivity and Adoption of EvidenceBased Programs

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Cultural Sensitivity and Adoption of
Evidence-Based Programs

• Nelda Mier, Ph.D.
• Assistant Professor
• School of Rural Public Health
• Social and Behavioral Health Department
• South Texas Center

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HOW CULTURALLY DIVERSE ARE WE?

• The U.S. Census Bureau uses 5 race categories
• American Indian and Alaska Native
• Asian
• Black or African American
• White
• Native Hawaiian and Other Pacific Islander

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U.S CENSUS BUREAU

• Race and Hispanic origin are separate and
  distinct concepts.
• Hispanic" or "Latino" are those who classify
  themselves as
• Mexican
• Puerto Rican
• Cuban
• Other Spanish, Hispanic, or Latino."

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HISPANIC OR LATINO

• U.S. Bureau Census
• Origin can be considered as the heritage,
  nationality group, lineage, or country of birth
  of the person or the persons parents or
  ancestors before their arrival in the United
  States.
• People who identify their origin as "Spanish,"
  "Hispanic," or "Latino" may be of any race.

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HOW MANY RACES ARE REPORTED?

• In 2000, the total population 281,421,906.
• 98 of the population reported only one race,
  with a majority reporting to be White.

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BY RACE
BY 2050.
U.S. Bureau Census
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The largest minority

• More than 1 in 8 people are Hispanic
• 2 in 5 Hispanics are foreign born
• The Hispanic population became the largest
  minority group by increasing 67 --22.4 million
  in 1990 to 37.4 million in 2002, excluding Puerto
  Rico and other islands

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U.S. Bureau Census 2000
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U.S. Bureau Census 2000 Total population 11
million
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WHERE IN THE US?
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of the Population that are White alone (2006)
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of the Population that are Black alone (2006)
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of the Population that are Asian alone (2006)
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of the Population that are American Indian and
Alaska Native alone (2006)
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of the Population that are Native Hawaiian and
other Pacific Islander alone (2006)
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• HOW MUCH DIVERSITY TO YOU SEE AROUND?

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DIVERSITY AND DISPARITIES
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Health Disparities

• Minorities experience a disproportionate burden
  of preventable disease, death, and disability
  compared with non-Hispanic Whites

Williams DR, Collins C. U.S. socioeconomic and
racial differences in health. In LaVeist TA,
editor. A public health reader. Race, ethnicity,
and health. San Francisco, CA Jossey-Bass 2002.
p. 391-431.
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Millard AV, Graham MA, Mier N, Flores I,
Carrillo-Zuniga G, Sánchez ER. Addressing
Health Disparities The Hispanic Perspective. In
S. Kosoko-Lasaki, R.L. O'Brien C.T. Cook
Eds.. Promoting Cultural Proficiency in
Eliminating Health Disparities. Boston Jones
Bartlett Publishers. (In Press.)
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Millard AV, Graham MA, Mier N, Flores I,
Carrillo-Zuniga G, Sánchez ER. Addressing
Health Disparities The Hispanic Perspective. In
S. Kosoko-Lasaki, R.L. O'Brien C.T. Cook
Eds.. Promoting Cultural Proficiency in
Eliminating Health Disparities. Boston Jones
Bartlett Publishers. (In Press.)
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CDC, 2005
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Percent higher loss of life among
Hispanics/Latinos compared with non-Hispanic
whites
Millard AV, Graham MA, Mier N, Flores I,
Carrillo-Zuniga G, Sánchez ER. Addressing
Health Disparities The Hispanic Perspective. In
S. Kosoko-Lasaki, R.L. O'Brien C.T. Cook
Eds.. Promoting Cultural Proficiency in
Eliminating Health Disparities. Boston Jones
Bartlett Publishers. (In Press.)
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Millard AV, Graham MA, Mier N, Flores I,
Carrillo-Zuniga G, Sánchez ER. Addressing
Health Disparities The Hispanic Perspective. In
S. Kosoko-Lasaki, R.L. O'Brien C.T. Cook
Eds.. Promoting Cultural Proficiency in
Eliminating Health Disparities. Boston Jones
Bartlett Publishers. (In Press.)
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• Why is important to understand cultural diversity
  and eliminate health disparities?

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• For health professionals, there is an ethical and
  moral dilemma that must be addressed. Their
  ethical standards demand fairness and compassion.
  
• Healthcare is a resource that is associated to
  social justice, opportunity, and quality of life.
  Health status is linked to productivity.

Institute of Medicine, 2002
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• From the perspective of public health, racial and
  ethnic disparities threaten efforts to improve
  the nations health.
• Racial and ethnic disparities in healthcare pose
  a significant dilemma to a society that is still
  dealing with a legacy of racial discrimination.

Institute of Medicine, 2002
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How do we address ethnic and racial health
disparities?

• Studies examining disparities
• Studies implementing culturally sensitive
  interventions

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WHAT IS CULTURE?

• Race, ethnicity, and cultural are consistently
  used interchangeably in health promotion
  research, even though they are not synonymous
  terms.

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DEFINING CULTURE

• Integrated patterns of human behavior that
  include language, thoughts, communications,
  actions, customs, beliefs, values and
  institutions of racial, ethnic, religious or
  social groups (16)
• Unique shared values, beliefs, and practices that
  are
• - Directly associated with a health-related
  behavior
• - Indirectly associated with that behavior
• - Influencing acceptance and adoption of the
  health education message or activity. (15)

15.Pasick RJ DOC, Otero-Sabogal, R. Similarities
and differences Across Cultures Questions to
Inform a Third Generation for Health Promotion
Research. Health Education Quarterly
199623(Suppl)S142-S161. 16.Assuring cultural
competence in health care Recommendations for
national standards and outcomes-focused research
agenda. In Health USDoHaHSOoM, editor.
Washington, DC U.S. Government Printing Office
2000.
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How do we operationalize culture?

• Race, ethnicity, language, nationality, and even
  geographic location are most commonly used as
  proxies for culture.

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How does culture influence health behaviors?

• African Americans have a perception that eating
  healthy means giving up part of their cultural
  heritage and trying to conform to the dominant
  culture.(18)
• Compared with White women, African American women
  are more satisfied with their weight and, if
  overweight, are more likely to feel
  attractive.(19)

18. James DC. Factors influencing food choices,
dietary intake, and nutrition-related attitudes
among African Americans application of a
culturally sensitive model. Ethnicity health
20049(4)349-67. 19. Eyler AA, Matson-Koffman D,
Vest JR, Evenson KR, Sanderson B, Thompson JL, et
al. Environmental, policy, and cultural factors
related to physical activity in a diverse sample
of women The Women's Cardiovascular Health
Network Project--summary and discussion. Women
health 200236(2)123-34.
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• Another study found that Latina women believe
  that sports are for men and that family and
  children come before personal needs (such as
  being physically active). (20)
• Other studies found that Hispanics believe that
  diabetes is caused by emotional trauma.(21)

20. Evenson KR, Sarmiento OL, Macon ML, Tawney
KW, Ammerman AS. Environmental, policy, and
cultural factors related to physical activity
among Latina immigrants. Women health
200236(2)43-57. 21. Arcury TA, Skelly AH,
Gesler WM, Dougherty MC. Diabetes meanings among
those without diabetes explanatory models of
immigrant Latinos in rural North Carolina. Soc
Sci Med 200459(11)2183-93.
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How DOES your cultural OR social background
influence your health behaviors?
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How do we address ethnic and racial health
disparities?
GOING BACK TO OUR QUESTION..

• Studies examining disparities
• Studies implementing culturally sensitive
  interventions

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Cultural Sensitivity

• The extent to which ethnic or cultural
  characteristics, experiences, norms, values,
  behavior patterns, and beliefs of a target
  population, and relevant historical,
  environmental, and social forces are incorporated
  in the design, delivery, and evaluation of
  targeted health interventions.

Resnicow K, Braithwaite RL, Dilorio C, Glanz K.
Applying theory to culturally diverse and unique
populations. In Glanz K, Rimer BK, Lewis FM,
editors. Health behavior and health education
theory, research, and practice. 3rd ed. San
Francisco, CA Joseey-Bass 2002. p. 485-509.
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Other terms

• Cultural Competence
• Multicultural
• Culturally appropriate, relevant, congruent,
  specific.

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Tailoring or Targeting?

• Targeting denotes a process of identifying a
  population subgroup for the purpose of insuring
  exposure to the intervention by that group. E.g.
  targeting an ethnic group.

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Tailoring or Targeting?

• Tailoring implies adapting the intervention to
  best fit the needs and characteristics of a
  target population. (15)
• Cultural tailoring is the development of
  interventions, strategies, messages, and
  materials to conform with specific cultural
  characteristics.(15)

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How do we tailor an intervention to be culturally
sensitive?

• Innovate?

Adopt an evidence-based program?
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Anatomy of Culturally Sensitive Interventions

• Literature review of RCTs testing nutrition and
  exercise interventions tailored for Hispanics
• Principles and components of these interventions.

Mier N, Ory MG, Medina AA. Anatomy of Culturally
Sensitive Interventions Promoting Nutrition and
Exercise in Hispanics A Critical Examination of
Existing Literature Submitted to Health Promotion
Practice. In review.
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STUDY DESIGN

• (1) described an intervention that was tailored
  for Hispanics (2) the intervention aimed at
  modifying knowledge, beliefs, or behavior related
  to nutrition or exercise (3) the intervention
  was tailored for Hispanics of any age group (4)
  the study was based on the randomized controlled
  trial research design (5) the study was
  published in a peer review journal, (6) the study
  was conducted in the United States and (7) the
  study was published between 1990 and 2006.

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THEORY-DRIVEN
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OPERATIONAL DEFINITION NONE
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ACCULTURATION
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FORMATIVE RESEARCH
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ETHNIC TERM
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SUFRACE STRUCTURE COMPONENTS
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DEEP STRUCTURE COMPONENTS
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RECRUITMENT STRATEGIES

• Not much detail
• Settings
• Community agencies
• Churches
• Schools
• Media

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LESSONS LEARNED I

• Theory-driven, yes. But
• 1st Determine a specific health issue for which
  an intervention is needed
• 2nd Identify the theories from a socioecological
  perspective and select the most appropriate one
  for understanding causal factors and processes of
  specific health-behaviors
• 3rd Determine potential points of interventions
  suggested by the selected theory or framework
• 4th Consider the collective wisdom on what
  interventions work with what populations under
  what conditions

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PRECEED-PROCEED model
http//www.lgreen.net/precede.htm
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PEN-3 model

• Influenced by the health belief model, theory of
  reasoned action, and PRECEED-PROCEED model
• Culture is the core of health promotion and
  disease prevention programs
• Used to assess cultural eating patterns and to
  develop AIDS prevention programs.(18)

(Airhihenbuwa 1995) 18. James DC. Factors
influencing food choices, dietary intake, and
nutrition-related attitudes among African
Americans application of a culturally sensitive
model. Ethnicity health 20049(4)349-67.
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PEN-3 MODEL
RELATIONSHIPS EXPECTATIONS
CULTURAL EMPOWERMENT
Perceptions Enablers Nurturers
Positive Existential Negative
Person Extended Family Neighborhood
CULTURAL IDENTITY
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Socioenvironmental framework

• Acknowledges the role of social and cultural
  influences in health behavior
• Emphasizes the transactions between individual
  and the environment at different levels
  individual, family, community, environment.

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Social Marketing Theory

• It uses a consumer orientation, audience analysis
  and segmentation, and aspects of exchange theory.
  

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RE-AIM MODEL
Reaim.org
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Participatory Approach

• It emphasizes the idea that communities
  themselves can achieve social and behavioral
  outcomes and that social forces influence
  behaviors.

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LESSONS LEARNED II

• Formative research plays an important role in the
  design and implementation of an intervention for
  Hispanics.
• Health assessments, focus group discussions,
  literature searches, and interviews are tools for
  tailoring an intervention by identifying
  attitudes, beliefs, language use, and other
  opinions of the priority population in relation
  to specific health issues or behaviors

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LESSONS LEARNED WITH HISPANICS III

• The diversity of the Hispanic population must be
  acknowledged in intervention design
• Consider immigration and contextual factors in
  intervention design
• Consider acculturation, but also understand that
  it is a complex phenomenon and more research is
  needed to better assess its impact on health
  outcomes.

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ACCULTURATION

• Level of immersion in the new culture or how far
  people have deviated from their cultural origins
  in adopting features of the new or dominant
  culture
• Conflicting evidence about the influence of
  acculturation on health behaviors (see table).

Lara M, Gamoa C, Kahramanian MI, Morales LS,
Hayes Bautista DE. (2005). Annu Rev Public
Health, 26, 367-97. Millard AV, Graham MA, Mier
N, Flores I, Carrillo-Zuniga G, Sánchez ER.
Addressing Health Disparities The Hispanic
Perspective. In S. Kosoko-Lasaki, R.L. O'Brien
C.T. Cook Eds.. Promoting Cultural Proficiency
in Eliminating Health Disparities. Boston Jones
Bartlett Publishers. (In Press.)
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LESSONS LEARNED IV

• Salient culturally sensitive intervention
  components are
• Bilingual and bicultural facilitators and
  materials
• Family-based activities
• Literacy-appropriate materials
• Social support.
• Having a clear understanding of Hispanic cultural
  values is also required.

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ADAPTING EVIDENCE-BASED INTERVENTIONS

• Evidence-based programs must use a program
  structure and curriculum that have been proven
  through prior research to be beneficial for
  participants.
• Incorporate measurable goals so that program
  managers can further evaluate and document their
  benefits in different settings and populations.

Mary Altpeter, Ph.D., Healthy Aging Briefing
Series The Basics of Evidence-Based Health
Promotion Programming, July 20, 2006.
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Vamos a Caminar!

• Pilot study
• A walking program for low-income women of Mexican
  origin living in areas known as colonias in the
  Texas-Mexico border region.
• Stages of Change Model
• Community-based Participatory Research

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1.2 million people (U.S. Census 2006)
SOURCE The Rio Grande Valley Partnership/Chamber
of Commerce
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POPULATION GROWTH
(US Census Bureau, 2006)
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EDUCATION LEVEL (lt HS)
(US Census Bureau, 2006)
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(US Census Bureau, 2006)
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COLONIAS

• Unincorporated, impoverished settlements located
  along the U.S.-Mexico international boundary
  (Ward, 1999)
• Texas 1,524 colonias (N400,000) (Ward, 1999)
  60 of these colonias are located in Hidalgo
  County (Federal Reserve Bank of Dallas (FRBD),
  1995 Housing Assistant Council, 2000 Ward,
  1999).

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COLONIA RESIDENTS

• Average household income gt 834 month
• 70 of residents have less than high school
  education
• High unemployment rates (20 - 60, compared to
  7 at the state level) and a lack of medical
  services (FRBD).
• 50 of colonia residents are immigrants, mostly
  from Mexico (Dutton, Weldon, Shannon, Bowcock,
  Tackett-Gibson, Blakely et al., 2000).

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Vamos a Caminar!
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RESIDENT AND PROMOTORA INVOLVEMENT
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Program Adaptation

• Non-expensive
• Feasible activities

• Included topics of diabetes and exercise
• Addressed dogs problem
• Social activities
• Certificate
• Childrens issue

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Program Implementation

• The duration of the program was 12 weeks
• Program based on PA recommendations and
  encouraged participants to incorporate walking
  activities into their lifestyle.
• The groups met separately every week for 1-hour
• The promotoras worked with participants using a
  problem-solving, self-management approach to
  discuss physical activity behavior change
  strategies.
• Addressed challenges

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EVALUATING FIDELITY AND ACCEPTANCE

• Ninety-three percent of participants attended 88
  of the sessions
• According to the program fidelity assessment we
  conducted, the promotoras delivered every lesson
  of the program as planned
• Acceptance of the program was assessed through
  feedback sessions with participants.

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TRANSLATING AND DISSEMINATING EVIDENCE-BASED
PROGRAMS

• Theory driven and use of the community-based
  participatory research
• Feasibility issues cost, setting, training,
  language.
• Acculturation?
• Evaluation issues