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Article Interpretation Instructions You must then choose 1 of these articles to read and interpret. Interpreting the article means that you are clearly and succinctly communicating the findings of the article as well as the methods used. This is not an article summary, an article critique, or an article review. This is an article interpretation, so you must interpret the findings of the article as if you were communicating this information to an individual for whom you worked. This assignment must be 400–500 words and be formatted in current Turabian style, including a citation at the beginning (on the top of the first page of text rather than at the end in a bibliography). No sources other than the article, itself, are required for this assignment.
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A Qualitative Case Study Examining
Intervention Tailoring for Minorities
Nelda Mier, PhD; Marcia G. Ory, PhD; Deborah J. Toobert, PhD;
Matthew Lee Smith, PhD, MPH, CHES, CPP; Diego Osuna, MD, MPH;
James R. McKay, PhD; Edna K. Villarreal, MPH; Ralph J. DiClemente, PhD;
Barbara K. Rimer, DrPH
Objectives: To explore issues of
intervention tailoring for ethnic minorities based on information and
experiences shared by researchers
affiliated with the Health Maintenance Consortium (HMC). Methods:
A qualitative case study methodology was used with the administration of a survey (n=17 principal investigators) and follow-up telephone
interviews. Descriptive and content
analyses were conducted, and a synthesis of the findings was developed.
Results: A majority of the HMC
projects used individual tailoring
strategies regardless of the ethnic
background of participants. Followup interview findings indicated that
T
here is evidence that the overall
health of the US population has improved1-3 with social and behavioral
interventions playing a crucial role in the
key considerations in the process of
intervention tailoring for minorities
included formative research; individually oriented adaptations; and
intervention components that were
congruent with participants’ demographics, cultural norms, and social
context. Conclusions: Future research should examine the extent to
which culturally tailoring long-term
maintenance interventions for ethnic minorities is efficacious and
should be pursued as an effective
methodology to reduce health disparities.
Key words: cultural, tailoring,
ethnic minorities, disparities
Am J Health Behav. 2010;34(6):822-832
process.4,5 The Institute of Medicine (IOM)
(2006), however, has noted that ethnic
minorities experience higher mortality
and morbidity rates than do nonminorities.
Nelda Mier, Associate Professor and Edna K. Villarreal, Graduate Research Assistant both from the
Department of Social and Behavioral Health, School of Rural Public Health, McAllen Campus, Texas
A&M Health Science, McAllen, TX. Marcia G. Ory, Regents’ Professor and Matthew Lee Smith, Research
Associate both from Department of Social and Behavioral Health, School of Rural Public Health, A&M
Health Science Center, College Station, TX. Deborah Toobert, Senior Research Scientist, Oregon
Research Institute, Eugene, OR. Diego Osuna, Clinician Researcher, Kaiser Permanente Colorado
Institute for Health Research, Denver, CO. James McKay, Professor of Psychology in Psychiatry,
University of Pennsylvania Center on the Continuum of Care in the Addictions, and Philadelphia VAMC,
Philadelphia, PA. Ralph J. DiClemente, Chandler Professor, Emory University School of Public Health,
Atlanta, GA. Barbara K. Rimer, Dean, Alumni Distinguished Professor, NC Gillings School of Global
Public Health, Chapel Hill, NC.
Address correspondence to Dr Mier, Department of Social and Behavioral Health, School of Rural Public
Health, McAllen Campus, Texas A&M Health Science Center, 2101 S McColl Rd McAllen, TX 78572. Email: nmier@tamhsc.edu
822
Mier et al
Hispanics and African Americans experience more age-adjusted years of potential
life lost before age 75 than do non-Hispanic whites due to stroke, chronic liver
disease and cirrhosis, diabetes, and homicide. 6,7 Both Hispanics and African
Americans have higher rates of obesity
and report lower levels of physical activity
than those of non-Hispanic whites.6-8 Asian
populations suffer a higher incidence of
tuberculosis, certain types of cancer, and
Hepatitis B than do non-Hispanic whites.9
Native Americans are more likely to report poorer health outcomes than any
other ethnic group.10 In addition, disparities exist in access to health care and are
associated with higher mortality rates
among ethnic minority groups.1
The increasing diversification of the
United States underlines the need to address ethnic health disparities and weigh
the significance of using a cultural sensitivity paradigm in the design and dissemination of health interventions targeting
minorities. Whereas ethnic minorities
currently constitute about one third of the
US population, it is expected that by 2050
minorities will become the majority and
represent 54% of the national population.
It is also estimated that by 2050, the Hispanic population will grow almost 3-fold
(from 49 million to 132.8 million); the Asian
group will more than double from 14.4
million to 34.4 million; and the African
American population will increase almost
43% (to become 56.9 million).11 If ethnic
minorities continue to experience health
disparities,1,2,6-10 the estimated population
growth of these groups may exacerbate the
negative impact of these disparities.
Responding to both the IOM recommendation to eliminate disparities and
the NIH mandate for a more systematic
inclusion of ethnic minorities in research12,13 to reflect national demographic
trends will require, among other public
health strategies, the diffusion of effective health interventions that are culturally sensitive to ethnic minorities.
This paper through a case study approach aimed to explore ways in which
the Health Maintenance Consortium
(HMC) (a collective of 21 NIH-sponsored
research projects) addressed issues of
cultural tailoring explicitly for ethnic
minority participants. We wanted to understand to what extent, and what types
of, culturally sensitive strategies were
used by the consortium for tailoring mainAm J Health Behav.
 2010;34(6):822-832
tenance health interventions that were
inclusive of ethnic minority participants.
This case study is based on information and experiences shared by researchers who participated in the HMC. Consortium researchers were funded by NIH to
conduct studies to test different theoretical models for achieving long-term behavioral change. Intervention outcomes
in these studies included lifestyle behaviors associated to chronic disease (ie,
eating behaviors, physical activity, cigarette smoking, and alcohol consumption),
more risky behaviors (ie, suicide, drug
abuse, and HIV-related sexual behaviors),
and preventive practices (ie, mammography and mental health screening).
Cultural Sensitivity Paradigm
The cultural sensitivity paradigm guiding the process of intervention tailoring or
adaptation for diverse groups in public
health and behavioral research has
emerged from multiple disciplines, including health communication,14,15 psychology,16
substance abuse prevention,17-23 HIV research,24,25 and health care systems.26-30
The paradigm is not only consistent with
the movements of patient-centered care
and the chronic care model,31 but its relevance is also underscored within the
health-disparity literature addressing ethnic disparities.2,28,30,32
The concept of cultural sensitivity has
been used interchangeably as cultural
competence, cultural appropriateness, or
cultural consistency. Although there is
not a single theoretical framework or a
standard definition in reference to the
cultural sensitivity paradigm, we defined
the concept as “the extent to which ethnic and cultural characteristics, experiences, norms, values, behavioral patterns,
and beliefs of a target population, and
relevant historical, environmental, and
social forces” (p493) are taken into account in intervention design, implementation, and assessment.33
The application and impact of the cultural sensitivity paradigm has also been
investigated. Considerable research supports the notion that addressing the individual needs and sociocultural context of
ethnic minorities in behavioral interventions results in statistically significant health-outcome modifications among
participants.34-39
Despite the emergence of cultural frameworks and the evidence showing that cul-
823
Tailoring for Minorities
Table 1
Survey Instrument Items and Interview Themes
Survey instrument items related to cultural sensitivity (the list of possible responses is not shown):
· In what ways have the treatment strategies that are being used in your study been adapted to be
culturally sensitive (cultural sensitivity refers to the extent to which ethnic/cultural characteristics,
experiences, norms, values, behavioral patterns, and beliefs of target populations are incorporated in the
design, delivery, and evaluation of your intervention materials . This might involve for example using
different recruitment strategies for different ethnic groups)?
· To what extent has the content of your intervention strategies been adapted to be culturally sensitive?
· In what language(s) are the intervention materials provided?
· What formats/considerations were used to address issues regarding literacy in these materials?· Are your
interventionists required to speak a language other than English?
· Are your interventionists required to meet specific criteria regarding age, gender, race/ethnicity, and/or
other?
Theme guide with open-ended questions used in follow-up interviews:
· What minority groups did you target?
· How did you tailor the intervention to be culturally sensitive for this group?
· What formative research activities did you conduct to tailor the intervention?
· What are the main components that made your intervention culturally sensitive?
· What lessons did you learn from tailoring your intervention to minority participants?
· What worked and what did not? What would you do differently in future studies?
turally tailored interventions are effective
in improving, in the short term, the health
status of ethnic minorities,34-39 there is
paucity of studies examining cultural sensitivity applications in long-term maintenance of behavior change in minority
health research. This case study, therefore, was proposed as an instructive exercise to gain insights on culturally sensitive issues as addressed by HMC researchers.
Background of the Health
Maintenance Consortium
The case study consortium was established in 2004 with funding from the
National Institutes of Health (NIH). The
HMC is a collective of 21 behavioral research projects focused on understanding the long-term maintenance of behavior change as well as identifying intervention components for achieving sustainable health promotion and disease
prevention. Coordinated by the NIH Office
of Behavioral and Social Sciences Research, the HMC comprised NIH administrators, 21 research investigators in the
United States, and the HMC Resource
Center program staff and advisors.
METHODS
A qualitative case study methodology
824
was used for the study. The data collection process consisted of 2 phases: a descriptive analysis of data from a survey
administered to 17 HMC principal investigators (PIs) and telephone interviews
with 4 HMC PIs to follow up on issues of
cultural sensitivity specifically related to
ethnic minority participants.
Survey
Using a community-based participatory approach, a task force was established as part of the HMC activities to
investigate the role that different intervention strategies played in the longterm maintenance of behavior change.
The task force comprised 9 HMC members, including HMC PIs, advisors, and
staff and NIH administrators. We all participated on a voluntary basis. The goal of
the task force was to compile an inventory of interventions for projects affiliated
with the HMC and to identify intervention
components. Using a consensus process,
the task force designed a structured 52item questionnaire to be administered to
HMC PIs conducting studies that tested
the effects of long-term interventions.
The task force also established the content validity of the questionnaire. The
survey instrument was then pilot tested
to assure it met the group’s aim and to
Mier et al
Table 2
Studies Included in the Interview Data Analysis
Study 1
HIV Prevention Maintenance for African American Teens. Aim: To determine the efficacy of an
HIV maintenance prevention intervention to sustain condom-protected sexual intercourse among
African American females aged 14-20 years, over an 18-month follow-up period.
Study 2
!Viva Bien! This project was a cultural adaptation for Latinas of the Mediterranean Lifestyle
Program (MLP) (affiliated with HMC). Aim of the MLP and !Viva Bien!: To improve multiple
health behaviors in postmenopausal women with type 2 diabetes
Study 3
Finding the M.I.N.C. for Mammography Maintenance. Aim: To identify the minimum
intervention needed for change for annual mammography use and maintenance among women of
diverse occupations and backgrounds.
Study 4
Weight Loss Maintenance in Primary Care. Aim: To evaluate 2 interventions for weight loss
maintenance in primary care patients recruited by their physicians.
test its readability and comprehension.
The instrument was administered via email to 21 PIs. A total of 17 PIs responded.
The survey queried the PIs about the
characteristics of their interventions,
including topics related to ways in which
the intervention was tailored to be culturally sensitive.
For purposes of this case study, we
examined data obtained from responses
to only 6 close-ended items included in
the instrument survey. These 6 items
were related to cultural sensitivity (as
shown in Table 1). The data were analyzed using descriptive statistics.
After written consent was obtained,
interviews with the 4 PIs were conducted
by telephone and recorded. All interviews
were transcribed verbatim. For Study 2,
the PI and a research team member were
interviewed, but both interviews were
treated as one set of data or transcript.
Transcripts were reviewed independently.
Then, using a focused coding process in
which concepts that emerged throughout
the data were identified, transcript findings were combined into larger, overreaching themes.40 This study was approved by the Texas A&M University Institutional Review Board.
Follow-up Interviews
In addition to analyzing the survey data
collected by the task force, authors of this
paper also conducted telephone interviews
with 4 HMC PIs to expand on issues of
cultural-tailoring processes applied to ethnic minority groups. The interviews were
based on a theme guide (Table 1).
Principal investigators who responded
to the survey (n=17) were asked to state
via e-mail whether or not they tailored
their interventions to make them culturally sensitive for ethnic minority participants. Of the 17 PIs who replied to the email inquiry, 4 responded affirmatively.
One of the interviews was related to an
intervention not affiliated to HMC, but
was nevertheless considered because the
PI culturally adapted the HMC-related
intervention to an ethnic minority group.
A description of the 4 studies is shown in
Table 2.
RESULTS
Survey Instrument Data
The descriptive analysis of survey responses revealed that the most frequent
tailoring strategy was matching intervention schedules with participants’
availability (76.5%). Another prevailing
strategy was delivering the intervention
in accessible locations to participants or
meeting their transportation needs
(64.7%).
Half of the HMC projects tailored the
interventions based on formative research. In addition, 8 studies (47%) reported that their interventions were delivered by individuals who were knowledgeable of the cultural views and values
of participants (it is worth noting that the
descriptive data did not capture details or
examples of such cultural views and values; Table 3).
Almost 2 thirds of the HMC studies
Am J Health Behav.
 2010;34(6):822-832
825
Tailoring for Minorities
Table 3
Percentage of HMC Projects (n=17 ) by
Intervention Tailoring Strategy
Intervention tailoring strategiesa
%b
The design of the treatment strategies was based on formative research experiences, norms,
beliefs, values, behavioral patterns, socioeconomic level, or other cultural characteristics
of participants.
58.8
Recruitment staff are from the participants’ community.
11.8
The treatment strategies include activities that involve family and friends of participants.
29.4
The intervention delivery setting was selected to make it accessible to, or meet the
transportation needs of, participants (eg, community setting, church, neighborhood).
64.7
The delivery of the intervention is facilitated by individuals or organizations from the
participants’ community (eg, community health workers, community leaders).
11.8
The intervention delivery schedules were adapted to match the participants’ availability.
76.5
The treatment strategies address trust issues related to research participation.
23.5
The interventionists are knowledgeable of cultural views and values of participants.
47.1
The interventionists’ racial/ethnic background is matched to the participants.
11.8
The interventionists’ age is matched to the participants.
5.9
The interventionists’ gender is matched to the participants.
Recruitment was done in minority newspapers, churches, and community events.
17.6
5.9
Intervention content was based on the socioeconomic status of the participants.
35.3
Intervention content was developed to match the participants’ cultural views and values.
23.5
Intervention content was developed to match the participants’ literacy level.
58.8
Intervention content was developed in the preferred language of the participants.
23.5
Notes.
a This is the list of statements as presented in the survey instrument. Survey respondents were
asked to check each statement that applied to their study.
b Percentage of respondents that checked the corresponding item box
developed intervention contents that met
the literacy level of the target population
(Table 3). All interventions were delivered in English, and only one reported
having an interpreter in the intervention
classes.
All 17 projects included some ethnic
minority participants. The average percentage of ethnic minority inclusion was
826
40.18%, and the range was from 6% to
100%, with only one study having all
participants from an ethnic minority
group (Figure 1).
Follow-up Interview Data
Three major themes emerged from data
obtained through the follow-up interviews:
the importance of formative research in
Mier et al
Figure 1
Percentage of Ethnic Minority Participants by Study (n=17)
cultural tailoring, intervention cultural
components, and main lessons learned.
Formative Research
The intervention tailoring process in 3
projects was informed by formative research including literature searches, focus groups, interviews, theatrical testing, and pilot testing:
You can read the literature, but unfortunately, even the African American
community is not homogeneous. So if
you were dealing with Caribbean Americans, African Americans, or Africans,
people who have lived in the North
versus the South, there really are some
differences that need to be taken into
account. The only way to really get at
those nuanced differences is by doing
some in depth formative work.
(Study 1)
Study 2 began the formative process by
searching the literature for “some insights into things that we should consider
changing from the parent program [The
Mediterranean Lifestyle Program]. There
could be some factors unique to Latinas
Am J Health Behav.
 2010;34(6):822-832
that would make a difference in terms of
learning self- management procedures.
In that literature we frankly didn’t find
anything that was very profound.”
Study 2 also conducted focus groups,
but again “we were left with the sense
that the overall format in the parent program was feasible for implementation
with Latinas. Childcare and transportation were 2 of the areas the participants
thought we should be sensitive to because they thought the intervention would
be rather demanding.”
Study 1 conducted 2 pilots assessing
the feasibility and cultural appropriateness of the program: “The pilot studies
were sort of a dress rehearsal. We went
through all the procedures, including randomization, and we delivered our intervention, and at the end of each intervention session, that’s when we requested
specific informa …
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