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Cultural Sensitivity and Adoption of EvidenceBased Programs

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Title: Cultural Sensitivity and Adoption of EvidenceBased Programs


1
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

2
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

3
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."

4
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.

5
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.

6
BY RACE
BY 2050.
U.S. Bureau Census
7
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
10
U.S. Bureau Census 2000 Total population 11
million
11
WHERE IN THE US?
12
of the Population that are White alone (2006)
13
of the Population that are Black alone (2006)
14
of the Population that are Asian alone (2006)
15
of the Population that are American Indian and
Alaska Native alone (2006)
16
of the Population that are Native Hawaiian and
other Pacific Islander alone (2006)
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  • HOW MUCH DIVERSITY TO YOU SEE AROUND?

20
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.
31
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.)
32
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.)
33
CDC, 2005
34
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.)
35
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.)
36
  • Why is important to understand cultural diversity
    and eliminate health disparities?

37
  • 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
38
  • 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
39
How do we address ethnic and racial health
disparities?
  • Studies examining disparities
  • Studies implementing culturally sensitive
    interventions

40
WHAT IS CULTURE?
  • Race, ethnicity, and cultural are consistently
    used interchangeably in health promotion
    research, even though they are not synonymous
    terms.

41
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.
42
How do we operationalize culture?
  • Race, ethnicity, language, nationality, and even
    geographic location are most commonly used as
    proxies for culture.

43
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.
44
  • 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.
45
How DOES your cultural OR social background
influence your health behaviors?
46
How do we address ethnic and racial health
disparities?
GOING BACK TO OUR QUESTION..
  • Studies examining disparities
  • Studies implementing culturally sensitive
    interventions

47
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.
48
Other terms
  • Cultural Competence
  • Multicultural
  • Culturally appropriate, relevant, congruent,
    specific.

49
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.

50
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)

51
How do we tailor an intervention to be culturally
sensitive?
  • Innovate?

Adopt an evidence-based program?
52
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.
53
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
58
ACCULTURATION
59
FORMATIVE RESEARCH
60
ETHNIC TERM
61
SUFRACE STRUCTURE COMPONENTS
62
DEEP STRUCTURE COMPONENTS
63
RECRUITMENT STRATEGIES
  • Not much detail
  • Settings
  • Community agencies
  • Churches
  • Schools
  • Media

64
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

65
PRECEED-PROCEED model
http//www.lgreen.net/precede.htm
66
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.
67
PEN-3 MODEL
RELATIONSHIPS EXPECTATIONS
CULTURAL EMPOWERMENT
Perceptions Enablers Nurturers
Positive Existential Negative
Person Extended Family Neighborhood
CULTURAL IDENTITY
68
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.

69
Social Marketing Theory
  • It uses a consumer orientation, audience analysis
    and segmentation, and aspects of exchange theory.

70
RE-AIM MODEL
Reaim.org
71
Participatory Approach
  • It emphasizes the idea that communities
    themselves can achieve social and behavioral
    outcomes and that social forces influence
    behaviors.

72
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

73
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.

74
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.)
75
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.

76
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.
77
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

78
1.2 million people (U.S. Census 2006)
SOURCE The Rio Grande Valley Partnership/Chamber
of Commerce
79
POPULATION GROWTH
(US Census Bureau, 2006)
80
EDUCATION LEVEL (lt HS)
(US Census Bureau, 2006)
81
(US Census Bureau, 2006)
82
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).

87
Vamos a Caminar!
88
RESIDENT AND PROMOTORA INVOLVEMENT
89
Program Adaptation
  • Non-expensive
  • Feasible activities
  • Included topics of diabetes and exercise
  • Addressed dogs problem
  • Social activities
  • Certificate
  • Childrens issue

90
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

91
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.

92
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
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