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.     

The Contribution of Health Literacy to Disparities in Self-Rated Health Status and Preventive Health Behaviors in Older Adults

PURPOSE Health literacy is associated with a range of poor health-related outcomes. Evidence that health literacy contributes to disparities in health is minimal and based on brief screening instruments that have limited ability to assess health literacy. The purpose of this study was to assess whether health literacy contributes, through mediation, to racial/ethnic and education-related disparities in self-rated health status and preventive health behaviors among older adults.METHODS We undertook a cross-sectional study of a nationally representative sample of 2,668 US adults aged 65 years and older from the 2003 National Assessment of Adult Literacy. Multiple regression analysis was used to assess for evidence of mediation.RESULTS Of older adults in the United States, 29% reported fair or poor health status, and 27% to 39% reported not utilizing 3 recommended preventive health care services in the year preceding the assessment (influenza vaccination 27%, mammography 34%, dental checkup 39%). Health literacy and the 4 health outcomes (self-rated health status and utilization of the 3 preventive health care services) varied by race/ethnicity and educational attainment. Regression analyses indicated that, after controlling for potential confounders, health literacy significantly mediated both racial/ethnic and education-related disparities in self-rated health status and receipt of influenza vaccination, but only education-related disparities in receipt of mammography and dental care.CONCLUSIONS Health literacy contributes to disparities associated with race/ethnicity and educational attainment in self-rated health and some preventive health behaviors among older adults. Interventions addressing low health literacy may reduce these disparities.     

Beyond Lockdown: The Potential Side Effects of the SARS-CoV-2 Pandemic on Public Health

Lockdowns to contain the spread of the SARS-CoV-2 have disrupted routines and behaviors, which could lead to a worsening of lifestyle and an increase in the burden of non-communicable diseases. This study aimed to describe the changes in physical activity, diet, alcohol drinking, and cigarette smoking during lockdown. A self-administered online survey addressing adults living in a province in northern Italy was advertised through websites and social media. Citizens could access the survey in anonymity from 4 May until 15 June 2020. A total of 1826 adults completed the survey, with a worsening of physical activity (35.1%), diet (17.6%), alcohol drinking (12.5%), and cigarette smoking (7.7%) reported. In contrast, 33.5% reported an improvement in diet, 12.6% in alcohol drinking, 5.3% in physical activity and 4.1% in cigarette smoking. Female sex, young adult age, suspension of work activity, and symptoms of psychological distress were the factors associated with a greater likelihood of change, which was frequently for the worse. Lockdown had an impact on lifestyle, with some net beneficial effects on diet and mostly negative effects on physical activity. Public health measures should be implemented to avoid long-term negative effects of the lockdown, supporting individuals more prone to change for the worse.     

Health behaviors and utilization among users of complementary and alternative medicine for treatment versus health promotion

Objective. To compare the characteristics, health behaviors, and health services utilization of U.S. adults who use complementary and alternative medicine (CAM) to treat illness to those who use CAM for health promotion. Data Source. The 2007 National Health Interview Survey (NHIS). Study Design. We compared adult (age ≥18 years) NHIS respondents based on whether they used CAM in the prior year to treat an illness (n=973), for health promotion (n=3,281), or for both purposes (n=3,031). We used complex survey design methods to make national estimates and examine respondents' self‐reported health status, health behaviors, and conventional health services utilization. Principal Findings. Adults who used CAM for health promotion reported significantly better health status and healthier behaviors overall (higher rates of physical activity and lower rates of obesity) than those who used CAM as treatment. While CAM Users in general had higher rates of conventional health services utilization than those who did not use CAM; adults who used CAM as treatment consumed considerably more conventional health services than those who used it for health promotion. Conclusion. This study suggests that there are two distinct types of CAM User that must be considered in future health services research and policy decisions.     

Meta-Synthesis of Health Behavior Change Meta-Analyses

Objectives. We integrated and compared meta-analytic findings across diverse behavioral interventions to characterize how well they have achieved change in health behavior.Methods. Outcomes from 62 meta-analyses of interventions for change in health behavior were quantitatively synthesized, including 1011 primary-level investigations with 599 559 participants. Content coding suggested 6 behavioral domains: eating and physical activity, sexual behavior, addictive behaviors, stress management, female-specific screening and intervention behaviors, and behaviors involving use of health services.Results. Behavior change interventions were efficacious (mean effect sizes = 0.08–0.45). Behavior change was more evident in more recent meta-analyses; those that sampled older interventions and literatures or sampled more published articles; those that included studies that relied on self-report, used briefer interventions, or sampled fewer, older, or female participants; and in some domains (e.g., stress management) more than others (e.g., sexual behaviors).Conclusions. Interventions improved health-related behaviors; however, efficacy varied as a function of participant and intervention characteristics. This meta-synthesis provides information about the efficacy of behavioral change interventions across health domains and populations; this knowledge can inform the design and development of public health interventions and future meta-analyses of these studies.Change in health behavior remains essential for the prevention of premature morbidity and mortality. A recent review suggests that (1) 50% of premature deaths can be attributed to modifiable risk behaviors, (2) many health problems lack curative solutions, and (3) health prevention incurs lower costs and fewer iatrogenic effects than medical solutions.¹ As a consequence, public health experts have focused their efforts on health promotion to reduce negative health outcomes. Over several decades, research on change in health behavior has burgeoned, uniting many disciplines in service of promoting health and preventing disease.^2–4 Given the vastness of the literature, continued development of health promotion interventions depends on the ability of researchers to extract insight from prior efforts, a major challenge for researchers and public health officials involved in the development of behavioral health programs.Public health experts share a strong interest in the efficacy of health promotion interventions. With the growing numbers of intervention studies evaluating the success of behavior change techniques and meta-analytic reviews summarizing these studies, evaluating the efficacy of behavioral interventions can be challenging. Meta-analyses often vary by targeted health domain (e.g., condom versus alcohol use), sample (e.g., adolescents versus adults), intervention setting (e.g., community versus clinic), and assessed outcomes (e.g., single versus multiple outcomes). Moreover, some meta-analyses restrict their samples to published studies whereas others include unpublished reports. Development of health interventions is likely to be challenged by the variations among meta-analytic studies.We therefore used meta-analytic procedures to examine findings from prior meta-analytic reviews of health promotion literatures. This integration may permit researchers, practitioners, and policymakers to determine the success of behavioral interventions more broadly. By focusing on study, sample, and intervention characteristics reported in meta-analyses of health behaviors, this meta-synthesis may assist researchers in the design and development of behavior change interventions, thus having the potential to improve the science of health promotion; it can serve a similar function for future meta-analyses of related literatures. In our meta-synthesis, we focus on behavioral outcomes, the most definitive gauge of the success of an intervention,⁵ and examine factors that moderate intervention efficacy.     

Physical inactivity in the Baltic countries

BACKGROUND: Physical inactivity is a known risk factor for heart disease and obesity, two major health problems in the Baltic Republics. This study examined patterns of physical activity level in these countries, and correlates of leisure-time sedentary behavior. METHODS: Data from three national surveys of adults conducted in Estonia, Latvia, and Lithuania in 1997 were used. Respondents who provided information on their activity level were included in this study (Estonia: n = 2,018; Latvia: n = 2,303; Lithuania: n = 2,140). RESULTS: One in three Estonians and one in five Latvians and Lithuanians had a low physical activity level at work. Half the respondents (Lithuania: 60%, Latvia: 52%, Estonia: 43%) participated only in sedentary activities during their leisure time. Leisure-time sedentarity was inversely related to education level in men and women and with income in men. It was also associated with smoking in men and with inadequate vegetable intake in men and women. CONCLUSIONS: Sedentary behavior during leisure time should be a public health issue in the Baltic Republics. Health promotion strategies aiming at increasing leisure-time physical activity level will need to target the general population, but particularly individuals from lower socioeconomic strata.     

Parental Rule Socialization for Preventive Health and Adolescent Rule Compliance

This study examined family rules about nutrition, exercise, and sun protection in 164 parent–young adult children dyads. Both parents and their young adult children independently reported on health rules that they perceived throughout their child's adolescent years and the extent to which the rules were articulated, violations sanctioned, and modeled. Neither child nor parent perceptions of rule‐related communication during adolescence predicted current young adult behaviors for any of the 3 health domains. Perceived rule compliance during adolescence was predicted from rule articulation across health domains, whereas patterns for sanctioning and parental modeling varied by health domain. Parents reported higher rule articulation than was perceived by their children across health domains and selectively reported higher scores on both sanctioning and modeling.      

Incorporating Occupational Health Interventions in a Community-Based Participatory Preventive Health Program for Farm Families: A Qualitative Study

ABSTRACT

The purpose of this pilot study was to determine the willingness of the farm community to participate in a farm safety health initiative (expanding a community-based health program to include elements of the Certified Safe Farm program), as well as understand farmers' experiences with participation in the intervention. Focus groups and individual interviews were held to explore farmers' experience with the expanded health screening and on farm safety review. Results indicate that incorporation of the expanded intervention was well accepted amongst participants in this study.     

Spousal Concordance in Dietary Behaviors and Metabolic Components,and Their Association: A Cross-Sectional Study

This study aims to investigate spousal concordance in dietary behaviors, spousal concordance in metabolic components (MCs), and their association. A cross-sectional survey was conducted in Taiwan from November 2014 to May 2015. Matched-pair analysis, McNemar’s test, logistic regression analysis, and stratified analysis were performed. A total of 901 pairs of spouses (1802 participants) were analyzed. Husbands were less likely to report intakes of high-fiber food (OR_MP (matched pairs odds ratio) = 0.30, p < 0.0001), fish (OR_MP = 0.74, p = 0.0128), biscuits or cakes (OR_MP = 0.60, p < 0.0001), and fast food (OR_MP = 0.65, p = 0.01) compared with their wives. Husbands had significantly higher odds of being overweight (OR_MP = 2.34, p < 0.0001); and of having hypertension (OR_MP = 2.14, p < 0.0001), hypercholesterolemia (OR_MP = 1.75, p = 0.0007), hyperlipidemia (OR_MP = 2.96, p < 0.0001), and one or more metabolic components (composite MCs) (OR_MP = 2.50, p < 0.0001) compared with their wives. After adjusting for age and education, the spousal concordance in high-fiber food intake was inversely associated with the spousal concordance in composite MCs (aOR = 0.62, 95% CI = 0.44–0.88, p = 0.0074), whereas the spousal concordance in processed food intake was positively associated with the concordance in composite MCs (aOR (adjusted odds ratio) = 1.56, 95% CI (Confidence Interval) = 1.03–2.36, p = 0.034). An intervention study for couples with intakes of different fiber foods and/or processed foods is critical for future study, in order to test what kinds of fiber foods/processed foods are associated with the development of the spousal concordance of metabolic components.     

Worksite Interventions: A Methodological Exploration and Pilot Study Promoting Behavior Change

This paper explores the methodological implications of using multiple methods in conducting preventive interventions, employing the stages of change model as a conceptual framework. We discuss the issues involved in using three empirically supported interventions (expert systems, group support, and self-help manuals) in the context of promoting smoking cessation. Although these methods have been assessed in different contexts, they have not been combined using the worksite as the location of intervention. Worksite interventions have the potential to reach large numbers of people and facilitate changes in social and environmental norms, yet there is a need to further examine how various methods can be combined to facilitate behavior change. Implementation of two pilot studies in the worksite provides initial evidence of the feasibility of a theoretically-based multi-method approach to intervention.     

Smoking and Cancer Screening for Women Ages 42–75: Associations in the 1990–1994 National Health Interview Surveys

Background. Previous studies have found an association between current smoking and lower rates of mammography and Pap testing. The objective of this study was to investigate the association of smoking status with breast and cervical cancer screening across the 1990–1994 National Health Interview Surveys (NHIS). The NHIS provides a consistent set of independent and dependent variables across several surveys, with data collected by a similar in-person interview methodology from year to year. This report employs more databases than have been used in other analyses that have examined associations between smoking and cancer screening.Methods. Data were from the health promotion and cancer control supplements to the 1990–1994 NHIS. The target population was women ages 42–75. Associations were examined between smoking status (never, former, <1 pack/day, ≥1 pack/day) and three screening indicators: ever had a mammogram, mammogram in the past 2 years, and Pap test in the past 3 years. Sample sizes ranged from about 3000 to over 10,800 depending on the respective NHIS survey and dependent variable. Data analyses were conducted by bivariate and multiple logistic regression.Results. Women who smoked ≥1 pack of cigarettes per day were significantly less likely to have had mammography screening in all NHIS surveys, compared to women who never smoked. Adjusted odds ratios were 0.63 to 0.74 for ever had a mammogram, and 0.56 to 0.66 for mammography in the past 2 years. Women who smoked ≥1 pack per day also had lower Pap test rates than women who never smoked in 1992–1994 (adjusted odds ratios of 0.51–0.71). Results for lighter smokers were not as consistent. Former smokers often had significantly higher screening rates than never smokers.Conclusions. Research still needs to identify reasons for lower screening among women who smoke. Factors to explore include the social networks of smokers and broader health behavior patterns. Clinicians should consider heavier smoking as a marker for risk of not obtaining screening and make assessment of screening status a priority at each visit.     

Smoking and alcohol use in adolescence in Barcelona, Spain

The evolution of perceptions about alcohol and smoking and theiractual use by adolescents in Barcelona (Spain) between 1987and 1992 are presented. Data were obtained from two surveysbased on samples of 8th-grade schoolchildren (13–14 yearsold). Current smoking does not show significant changes (with10.7% reporting being regular smokers in 1992), and smokingexpectations decline for boys (but not for girls). In 1992,38.9% of students reported that their fathers smoke (a lowerfigure than the 49.8% reported in 1987), but mothers are reportedto be smokers by 20.9% (more than the 15.3% reported in theprevious survey). Concerning alcohol, fewer students in 1992reported daily drinking (1.8% of all surveyed students) andusual drinking (8.7%), while more reported having ever becomedrunk (22.4%), and no significant changes are seen for perceptionsof alcohol use except for a modest decline in the proportionwho reported having an older sibling who drinks usually. Overall,these results suggest that smoking incidence among 8th gradershas not declined, while changes are taking place in smokingprevalence in the adult population. They also suggest that dailyconsumption of alcohol has decreased, while alcohol abuse mayhave increased, a trend that may be linked with changing patternsof alcohol use in southern European countries like Spain. Thesedata provide a perspective on secular trends for tobacco andalcohol use in Barcelona, and the baseline for the evalutionof interventions targeting adolescents and implemented in thecity since 1992.     

Assessing Managed Care's Role in Promoting Preventive Care

The current trend of managed health care systems opens the door to more effective control of chronic diseases through preventive care. The goal of this study was to assess managed care's role in promoting preventive care. A mail survey was conducted of a national sample of 1,200 directors, associated with preventive care, in managed care organizations (MCOs) in the U.S. Data was obtained on perceived effectiveness, degree of importance, and likelihood of support for implementation of strategies recommended (case management, utilization review programs, selective contracting, and cost sharing) for ensuring appropriate utilization of preventive services. Also, information was collected on interventions perceived effective in encouraging plan members to utilize and providers to offer preventive services. Response rate was 17.3%. Case management and prospective and concurrent utilization review programs were perceived most effective, important, and likely to receive support for implementation while cost sharing (using deductibles and coinsurance) and retrospective utilization review programs ranked low on all dimensions. Plan member-directed interventions perceived effective in encouraging utilization of preventive services included telephone and mail reminders while computer-generated reminders and medical record audits with feedback were perceived effective in encouraging providers to offer such services. Results identified preferred MCO strategies and interventions for ensuring appropriate utilization of preventive services. Further research is needed to develop methods to encourage people at high risk for chronic diseases not currently utilizing preventive services to receive such services.