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Adapting health promotion interventions to meet the needs of ethnic minority groups: mixed-methods evidence synthesis
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Professor Raj Bhopal CBE
Professor Martin White
Dr Mark Deverill
Dr Alia Sheikh
Liu JJ, Davidson E, Bhopal RS, White M, Johnson MRD, Netto G, Deverill M, Sheikh A
Health Technology Assessment
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: To identify, appraise and interpret research on the approaches employed to maximise the cross-cultural appropriateness and effectiveness of health promotion interventions for smoking cessation, increasing physical activity and improving nutrition for African-, Chinese- and South Asian-origin populations.
: Theoretically-based, mixed methods, phased programme of research that involved user engagement, systematic reviews and qualitative interviews, which were integrated through a realist synthesis.
Two national conferences; seven databases for UK guidelines and international systematic reviews of health promotion interventions aimed at the general population; 11 databases for research on adapted health promotion interventions for ethnic minority populations; in-depth qualitative interviews with a purposive sample of researchers and health promoters.
Following a launch conference, two reviewers independently identified and extracted data from guidelines and systematic reviews on the effectiveness of interventions for the general population and any guidance offered in relation to how to interpret this evidence for ethnic minority populations. Data were thematically analysed. Reviewers then independently identified and critically appraised studies of adapted interventions, and summarised data to assess feasibility, acceptability, equity, effectiveness and cost-effectiveness. Interviews were transcribed, coded and thematically analysed. The quantitative and qualitative data were then synthesised using a realist framework to understand better how adapted interventions work and to assess implementation considerations and prioritise future research. Our preliminary findings were refined through discussion and debate at an end-of-study national user engagement conference.
Initial user engagement emphasised the importance of extending this work beyond individual-centred behavioural interventions to also include examination of community and ecological level interventions. However, individual-centred behavioural approaches dominated the 15 relevant guidelines and 111 systematic reviews we identified. The most consistent evidence of effectiveness was for pharmacological interventions for smoking cessation. This body of work, however, provided scant evidence on the effectiveness of these interventions for ethnic minority groups. We identified 173 reports of adapted health promotion interventions, the majority of which focused on US-based African Americans. This body of evidence was used to develop a 46-item Typology of Adaptation and a Programme Theory of Adapted Health Promotion Interventions. Only nine empirical studies directly compared the effectiveness of culturally adapted versus standard health promotion interventions, these failing to yield any consistent evidence; no studies reported on cost-effectiveness. The 26 qualitative interviews highlighted the need to extend thinking on ethnicity from conventional dimensions to more contextual considerations. The realist synthesis enabled the production of a decision making tool (RESET) to support future research.
There is currently a lack of evidence on how best to deliver smoking cessation, physical activity and nutrition related health promotion interventions to ethnic minority populations. Whilst culturally adapting interventions can increase salience, acceptability and uptake, there is as yet insufficient evidence on the effectiveness or cost-effectiveness of these adapted approaches. More head-to-head comparisons of adapted versus standard interventions are warranted. The Typology of Adaptation, Programme Theory of Adapted Health Promotion Interventions and the RESET tool developed should help researchers to develop more considered approaches to adapting interventions than has hitherto been the case.
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