Transcript The Science of Targeting and its Application in Health Care

The Science of Targeting and
its Application in Health Care
Lisa A. Cooper, MD, MPH
April 8, 2010
Goal: To describe how we learn about
group characteristics and develop skills
that foster better delivery of health care
Objectives
1. Describe approaches to enhancing cultural
sensitivity in health care
2. Provide examples of demographic, social, and
cultural targeting in marketing messages and health
care interventions
3. Identify effective strategies for demographic
targeting that optimize positive images and
minimize negative stereotypes and stigma
4. Explain how targeting and tailoring can be
combined to acknowledge individual differences
when designing population-level interventions
Targeting versus Tailoring
• Targeted interventions •
involve messages that
are intended to reach
population subgroups
based on a specific set of
shared characteristics
Tailored interventions,
involve messages that
are intended to reach
an individual based on
specific characteristics
of the individual as
measured in a formal
assessment process
Approaches to Enhancing Cultural
Sensitivity in Health Care
• Early programs: cross-cultural medicine, cultural
sensitivity, trans-cultural nursing, and multicultural
counseling
• Focused on those “whose health beliefs may be at
variance with biomedical models”
– e.g. groups with limited English proficiency, non-Western
cultures, etc.
• Original approaches called for awareness and respect
for different traditions, but recognized
– detailed knowledge about all cultures was impractical
– viewing patients as members of ethnic/cultural groups
might lead to stereotyping
Evolution of Cultural Competence
Early models recognized the need for “generic”
attitudes not specific to a particular culture:
1) respecting the legitimacy of patients’ health beliefs
2) shifting from a paradigm of viewing patients’ complaints
as stemming from a disease to that of an illness occurring
within a biopsychosocial context
3) eliciting patients’ explanatory model of illness
4) explaining the clinician’s explanatory model of illness in
language accessible to patients
5) negotiating an understanding within which a safe,
effective, and mutually agreeable treatment plan could be
implemented
Berlin & Fowkes (1983); Kleinman et al. (1978); Leininger (1978)
Disparities move to forefront of
national health agenda
Minority Health and Health Disparities
Research and Education Act of 2000
Healthy People 2010
1972
Tuskegee
Syphilis Study
becomes public
1970
Health Revitalization
Act of 1993 establishes
the Office of Research
on Minority Health
1985
DHHS Heckler
Report on Black
and Minority
Health
1980
1990
2003 IOM Report “Unequal
Treatment” and first
National Healthcare
Disparities Report published
2000
2007
2010
Expansion of Cultural Competence
Early models
Newer models
(cross-cultural)
(Cultural Competence)
Populations
Immigrants,
refugees
All people of color, other
disadvantaged groups
(those affected by health
disparities)
Concepts
Culture,
Language
Culture, Language,
Prejudice, Stereotyping,
Social Determinants of
Health
Scope
Interpersonal
interactions
Health Care Systems,
Communities
Definitions of Cultural Competence
• Interpersonal Cultural Competence
– The ability of individual health care professionals to
establish effective interpersonal and working relationships
with patients (and each other) that supersede cultural
differences1
• Health System Cultural Competence
– The ability of health care providers and organizations to
understand and respond effectively to the cultural and
linguistic needs brought by patients to the health care
encounter2
1Cooper
& Roter, 2OMH 2001
Organizational and Interpersonal
Cultural Competence
Within Interpersonal Interactions:
Within Health Care Organizations:
Ability of a provider to bridge
Ability of the health care
cultural differences to build
Culturally
organization to meet
an effective relationship
Competent Health
needs of diverse groups
with a patient:
Care Systems
of patients:
• Diverse workforce
reflecting patient
population
• Facilities convenient to
community
• Language assistance for
patients with limited
English proficiency
• Staff training regarding
delivery of culturally and
linguistically appropriate
services
• Culturally appropriate
health education
materials
Culturally
Competent
Health Care
Interactions
• Understands the meaning
culture
• Is knowledgeable about
different cultures
• Appreciates diversity
• Is aware of health
disparities and
discrimination affecting
minority groups
• Effectively uses interpreter
services when needed
Saha S, Beach MC, Cooper LA.
J Natl Med Assoc 2008;100: 1275-1285
Using Behavioral Models to Understand Ethnic
Differences in Care-Seeking for Depression
External Variables
Internal Variables
Demographics
Behavioral beliefs
Race, Ethnicity
Gender, Age,
Education
Effectiveness
Illness
variables
Medications
Attitudes toward
behavior
Treatment
acceptability
Counseling
Prayer
Plans to seek help
Perceived need
Treatment
Experience
Social Support
Behavioral
Intention
Value of outcome
Normative beliefs
Subjective norms
Family would be
disappointed
Employer stigma
Friend stigma
Life Events
Modified from The Theory of Reasoned Action (Azjen, 1996)
Behavior
Seeks
treatment
Sample Comments Made by Patients
in Depression Focus Groups
Spirituality
“I did pray a lot. I’m a Christian, and I would
pray and pray and find verses of scripture.”
African-American male, age 30
Cooper-Patrick L et al, JGIM 1997;12:431-438
Sample Comments Made by Patients
in Depression Focus Groups
Stigma
“And I didn’t want anyone to know that I
was taking this prescription. I just didn’t
want to feel like I was crazy.”
African-American female, age 53
Cooper-Patrick L et al, JGIM 1997;12:431-438
Sample Comments Made by Patients
in Depression Focus Groups
Patient-provider relationships
“This guy [my doctor] was just a plain old
nice guy, you know…he was very, very
sharp…I thought, whatever this guy tells me
for the most part, if it sounds sensible, I’ll
give it a try.”
African American male, age 28
Cooper-Patrick L et al, JGIM 1997;12:431-438
Sample Comments Made by Patients
in Depression Focus Groups
Attributes of treatment: Medicines
“If it’s gonna make me feel good, make
me feel good right away so I can get up
and start doing what I want to do. I don’t
want it to take a long time to kick in.”
female, age 41
Cooper-Patrick L et al, JGIM 1997;12:431-438
Sample Comments Made by Patients
in Depression Focus Groups
Attributes of treatment: Patient education
“When you explain to me what the medicine’s
going to do and what I can expect from it, I
feel much more comfortable.”
female, age 41
Cooper-Patrick L et al, JGIM 1997;12:431-438
Most Important Aspects of
Depression Care to Patients
1. Health provider interpersonal skills
2. Treatment effectiveness
3. Treatment problems
4. Patient education, information, and understanding
5. Intrinsic spirituality * (African Americans)
6. Financial access
7. Primary care provider recognition of depression
Cooper LA et al, Gen Hosp Psychiatry 2000;22:163-173
African Americans rate spirituality as
more important in depression care
All p-values
<0.05
Cooper LA et al, Journal of General Internal Medicine 2001;16:634-638
Views about depression differ among
Whites, Blacks, and Hispanics
I believe I need treatment
Medications are effective
Medications are addictive
Counseling is as effective as meds
Counseling brings up bad feelings
Prayer heals depression
Socially embarrassed
Family would be disappointed
Prefer same ethnicity/race provider
*p<0.05, **p<0.01, †p<0.001
White Blacks Hisp
n=659 n=97 n=72
68
70
68
91
69
84 †
34
56
51 **
50
57
74 **
50
71
71 **
67
93
67 †
24
24
33
16
15
22
14
25
13 *
Cooper LA et al. Med Care 2003;41:479-489
Physicians engage in less
depression talk and rapport-building
with depressed African Americans
P=0.07
P=0.30
P=0.04
P=0.01
Ghods BK, Roter D, Ford DE, Larson S, Arbelaez J, Cooper LA.
J Gen Intern Med 2008; 23:600-6
Questions to guide selection of
tailored vs. targeted message strategy
• Is there variability on the key determinants of
depression care-seeking?
– Tailoring: high
– Targeted: high or low
• Are there mechanisms for gathering individual-level
data from the target population?
– Tailored: needed
– Targeted: not needed
• What is the level of awareness or understanding of the
problem in the target population?
– Tailored: high
– Targeted: high or low
Black and Blue: A culturally targeted
videotape about depression
Sample comments made by
patients in videotape focus group
Theme
Most effective parts of the
videotape
Ways to improve the
videotape
Sample Comments
“I think having real people with real
problems was effective.”
“It would have been more effective if
maybe we had more specifics on
what caused their depression, and
how they got through it, and what
treatment worked for them.”
Identification with people “Depression, in the younger fellow
in the videotape
who talked, yes, everything he said
hit home to me.”
Primm AB, Cabot D, Pettis J, Vu HT, Cooper LA. J Natl Med Assoc 2000;94:1007-1016
Sample comments made by
patients in videotape focus group
Theme
Race,
ethnicity
and cultural
issues
Sample Comments
“I’ve never really paid much attention to videos in
the past because they mainly had Caucasians that I
couldn’t really relate to, and to sit here and watch
something with people who look like me, talk like
me, and went through what I went through, seeing
is believing that black people have gone through
this.”
“A lot of reasons we [blacks] don’t seek out this
help that we so desperately need, is because as
African-American children, we’re taught to be
strong-don’t let them see you cry. Then when you
show up you don’t know what to say, “ I need help,
can somebody help me?”
Sample comments made by
patients in videotape focus group
Theme
Sample Comments
Stigma and
stereotypes
“I was surprised to see so many men [in the
video] because a lot of times [depression] is
called the woman’s disease because men don’t
really get upset ‘cause they have a strong
backbone, so it was cool to see men going
though it.”
Spirituality
“The other thing [that was effective about the
video] as the faith piece, other people who are
of your faith that tell you, you don’t pray, you
need to pray harder, that’s all you need to do.
That’s not true.”
Agreement with statements about
medical aspects of depression
Primm AB, Cabot D, Pettis J, Vu HT, Cooper LA. J Natl Med Assoc 2000;94:1007-1016
Agreement with statements about
treatment effectiveness
Disagreement with statements
about treatment problems
Disagreement with statements
about spirituality
Disagreement with
statements about stigma
Strategies for effective targeting
• Optimize positive images
– Feature African Americans (regular and successful people)
who have experienced depression and gotten better
• Dispel misconceptions
– Discuss common myths and counteract with information
• Avoid negative stereotypes
– Depression is a medical illness, not a character weakness or
something to be ashamed of
• Reduce stigma
– Use public figures as role models
– Encourage relatives and friends of depressed individuals to
try to understand the illness and be supportive
Blacks Receiving Interventions for
Depression and Gaining Empowerment
• Design: Cluster randomized trial
• Population: 27 primary care providers and 132 African
American patients with depression
• Setting: 10 urban, community-based clinics in
Baltimore, MD and Wilmington, DE
• Interventions:
– Standard quality improvement program
– Patient-centered, culturally targeted program
• Outcomes: depression resolution, guideline-concordant
care, and patient ratings of care at 6 & 12 mo follow up
Supported by the Agency for Healthcare Research and Quality
Cooper LA, Ford DE, Ghods BK, et al. Implementation Science. 2010; 5(1):18
Patient-Centered
Intervention
Providers
N=15
Provider Recruitment
Standard
Intervention
Providers
N=15
Patient-Centered
Intervention
Patients*
N=125
Patient Recruitment
Standard
Intervention
Patients*
N=125
*DCM contacts for active follow-up up to 12 months
Bridge Study Primary Care
Clinician Intervention Features
Intervention
Two academic detailing
visits (CME credit)
Psychiatric consultation
liaison support
Communication skills
on interactive CD-ROM
Culture-specific
information
Standard
Intervention
X
PatientCentered
Intervention
X
X
X
X
X
Examples of Clinician Goals
•
•
•
•
•
Improve recognition
Evaluate associated conditions
Assess suicidal ideation
Change usual antidepressant
Identify patients’ cultural
beliefs
• Elicit patients’ preferences
Functions of the Medical Interview
•
•
•
•
Data-gathering
Patient education and counseling
Rapport-building
Facilitation and patient activation
Lipkin, Putnam, & Lazare, 1995
Interactive CD-ROM
Bridge Study Patient Interventions
Intervention
Standard
Intervention
PatientCentered
Intervention
Needs Assessment
Patient Centered Needs Assessment
X
Education and Activation
X
X
Social support/informal counseling
X
X
Standard education materials
X
X
Culturally targeted education materials
X
Black Mental Health Alliance List
X
Cultural information packet for MH
Providers
X
The standard needs assessment
is generic and disease-oriented
•
•
•
•
•
•
Depressive symptoms
Associated conditions
Functional Status/Activities affected
Stressors
Social Support
Treatment preferences
Standard Intervention
Patient Education Materials
• Brochure
• Book
• DVD
The patient-centered needs
assessment combines targeted and
tailored approaches
•
•
•
•
•
Meaning of illness from patient perspective
Perceptions of racial discrimination
Literacy and language concerns
Importance of spirituality in coping and care
Specific treatment concerns regarding
antidepressants or counseling
• Financial concerns
• Role of stigma
• Relationships with health professionals
Patient-Centered Intervention
Patient Education Materials
• Brochure
• Book
• Videotape
• Prayer card*
• Bridge
Study
calendar
*only
if patient is spiritually oriented and/or receptive
Patients rated the patientcentered depression care
manager as more helpful
*p<0.05
More patients read books and
brochures -- half watched videos
Most patients felt information
presented was helpful
Most patients could identify with
messages in the materials
More family members and close
friends used targeted materials
Conclusions
• Cultural targeting has been identified as a
potential strategy for overcoming disparities in
health care
• Behavioral models can be used to identify
appropriate content and strategies for targeting in
healthcare interventions and materials
• Gathering data/input from targeted groups can
enhance acceptability and uptake of interventions
• Combining targeting and tailoring improves
perceived relevance and minimizes stereotyping
Discussion Points
• What is the added benefit of targeting over generic
approaches for particular behaviors?
• For which groups is targeting most effective?
• How much customization of messaging is needed to
achieve relevance?
• When is customization perceived as negative?
• Should customization be implicit or explicit?
• What are the pros and cons of being more inclusive
versus more targeted in one’s approach?