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    A Systematic Review of Racial and Ethnic Disparities Intervention Literature

    Skip to Articles

    Overview

    Finding Answers: Disparities Research for Change conducts reviews of racial and ethnic disparities intervention literature to identify successful strategies and provide health care organizations, providers and payers with recommendations on how they can address disparities in their own organizations.

    Finding Answers' first set of systematic reviews was published as a special supplement to the October 2007 edition of Medical Care Research and Review: the study reviewed more than 200 articles that outline interventions that have the potential to reduce racial and ethnic disparities in the areas of cardiovascular disease, diabetes, depression and breast cancer.  Additionally, the research surrounding two specific approaches—cultural leverage and pay-for-performance incentives—was examined and provides insight for future intervention development.

    Finding Answers' second set of systematic reviews were published as a symposium in the August issue of the Journal of General Internal Medicine. These reviews focused on five additional disease areas: asthma, cervical cancer, colorectal cancer, HIV prevention, and prostate cancer.


    Successful Strategies

    Through the systematic review, it became clear that the following strategies were often part of successful interventions.

    Multifaceted Programs
    Successful interventions often involved multiple components targeting different levers of change such as providers, patients, and the community. 

    A Focus on Cultural Relevancy
    Culturally-tailored quality improvement approaches such as creating intervention materials (posters, pamphlets) with culturally congruent images and in languages other than English produced successful outcomes. The review found that interventions that utilized cultural leverage as a strategy to reduce disparities increased patient knowledge and understanding for self-care, decreased barriers to access, and improved multiple areas of cultural competence for health care providers.

    Nurse-led Programs
    Nurse-led patient-centered interventions within the context of wider systems change were found to be promising. Because nurses often spend more time with patients and can provide critical care coordination, they are in a unique position to affect change within an organization.

    Interactive Education
    For programs that utilized education as an intervention strategy, interactive education and skills-based training was found to be more successful than traditional didactic, knowledge-based training.

    Family and Community Programs
    Patient navigation and interventions that actively involved family and community members in patient care showed promise for improving minority health outcomes.


    Key Findings

    Key findings from the 2012 reviews of literature in each disease area:

    A Roadmap to Reduce Disparities
    Five systematic reviews examined interventions to improve minority health and potentially reduce disparities in asthma, HIV, colorectal cancer, prostate cancer and cervical cancer. The five reviews focused on interventions that occur in or have a sustained link to a health care delivery setting, examined racial and ethnic disparities in care and improvements in minority health, rather than geographic, socioeconomic, or other disparities. Based on these reviews, evaluating promising practices, and providing technical assistance to health care organizations, Finding Answers presents a roadmap for reducing racial and ethnic disparities in care. The Roadmap to Reduce Disparities Fact Sheet

    Asthma
    Authors conducted a systematic review of the literature to characterize interventions with potential to improve outcomes for minority patients with asthma. Overall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. System redesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Asthma Review Fact Sheet

    Cervical Cancer
    The authors systematically reviewed 31 studies that focused on U.S. racial and/or ethnic minorities who were linked to a health care system. They found that in order to improve the rate of screening for cervical cancer in minority patients, telephone support with navigation and education programs by lay health educators with navigation may be of benefit. In order to improve the diagnosis and treatment of premalignant disease of the cervix, a single visit for screening for cervical cancer and follow-up of an abnormal result may be of benefit, as may telephone counseling. Cervical Cancer Review Fact Sheet

    Colorectal Cancer
    The authors reviewed 33 studies, from 1950 to 2010, of interventions in U.S. populations eligible for colorectal cancer screening, and composed of greater than 50 percent racial or ethnic minorities. They found that tailored patient education combined with patient navigation services and physician training in communicating with patients of low health literacy can modestly improve adherence to colorectal cancer screening among racial and ethnic minority patients. Looking forward, interventions to improve post-screening follow-up and receipt of life-saving therapy for those diagnosed with colorectal cancer are imperative if we expect the racial and ethnic survival gap to close. Colorectal Cancer Review Fact Sheet

    HIV
    Authors conducted a systematic review of the past 30 years of HIV prevention interventions addressing racial disparities. They found that an intervention that includes skills-based instruction and is successfully tested in an adolescent population may be adapted for a variety of aims, as long as the core elements of skill-based content and appropriate cultural targeting remain. However, no study was identified that sought specifically to reduce racial disparities in the sexual acquisition of HIV. HIV Prevention Fact Sheet

    Prostate Cancer
    Twelve of 13 studies that used educational programs, print materials, videotapes/DVDs or the Web for enhancing informed decision making about prostate cancer screening showed statistically significant increases in knowledge. Educational programs showed the greatest percentage increase in knowledge across studies. Of the five cognitive-behavioral interventions reviewed, all improved quality of life among minority men being treated for localized prostate cancer by enhancing problem solving and coping skills. Going forward, a much stronger evidence base for the use of such interventions to improve informed decision making across the clinical spectrum for prostate cancer is essential; especially necessary are more studies that address the role of behavioral interventions to support informed decision making in minority patient coping skills. Prostate Cancer Review Fact Sheet 

     

    Key findings from the 2007 reviews of literature in each disease area:

    Diabetes
    Most of the diabetes intervention literature focused on improvements in health care delivery and outcomes. The researchers found that effective diabetes patient interventions were culturally-tailored. Effective provider interventions incorporated one-on-one feedback and education. Successful health systems interventions effectively engaged nurse case managers and nurse clinicians.

    Depression
    The literature showed that multi-component chronic disease management interventions have produced improvements in depression outcomes for ethnic minority populations. Case management appears to be a key component of effective interventions and socio-culturally tailored treatment and prevention interventions may be more efficacious than standard treatment programs.

    Breast Cancer
    A majority of the breast cancer literature involved screening rather than diagnostic testing or treatment interventions. Among patient-targeted screening interventions, those that were culturally tailored or addressed financial or logistical barriers were generally more effective than reminder-based interventions. Chart-based reminders increased physician adherence to mammography guidelines but were less effective at increasing clinical breast examination. Case management was found to be an effective strategy for expediting diagnostic testing after screening abnormalities have been found.

    Cardiovascular Disease
    This review addressed cardiovascular risk factors (hypertension, hyperlipidemia, physical inactivity, tobacco), and cardiovascular conditions (coronary artery disease ,heart failure). Researchers found that most interventions focus on improving the care of African-American populations, with relatively little work in Hispanic, Asian, and American Indian populations.  Promising interventions for cardiovascular disease include organization level interventions such as registries, interventions involving nurses and pharmacists, contacting patients between clinic visits, and community outreach.


    Future Directions

    There is still much work to be done in disparities research and in developing effective interventions. Although this review identified several promising strategies that can be built on, it also pointed to the need for additional work and areas where questions still exist.

    Moving forward, disparities should be studied in underrepresented populations such as American Indian, Asian American, and pediatric ethnic and geriatric ethnic subgroups. The effect of quality improvement policies, such as pay-for-performance incentives, should be measured to promote a narrowing, as opposed to neutral or widening, effect on disparities. Funding agencies should invest in expanded and coordinated research portfolios to better explain the causes and consequences of health disparities and develop interventions to promote equitable health care and health outcomes. Policy makers should help pave the way to establishing national data structures to monitor the impact of these interventions on the quality of care patients receive.

    The United States still has a great distance to travel before racial and ethnic disparities in care can be eliminated.  However, there is reason for optimism based upon the early lessons from the existing literature.   By enhancing knowledge and problem-solving ability in this critical area, practical solutions to end racial and ethnic disparities in health care are possible.


    Articles

    2012 Systematic Reviews, Journal of General Internal Medicine

    A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care
    Journal of General Internal Medicine
    Volume 27, Number 8 (2012), 992-1000, DOI: 10.1007/s11606-012-2082-9
    Abstract  PDF

    Interventions to Improve Outcomes for Minority Adults with Asthma: A Systematic Review
    Journal of General Internal Medicine
    Volume 27, Number 8 (2012), 1001-1015, DOI: 10.1007/s11606-012-2058-9
    Abstract  PDF

    Cervical Cancer Screening, Diagnosis and Treatment Interventions for Racial and Ethnic Minorities: A Systematic Review
    Journal of General Internal Medicine
    Volume 27, Number 8 (2012), 1016-1032, DOI: 10.1007/s11606-012-2052-2
    Abstract  PDF

    Interventions to Improve Care Related to Colorectal Cancer Among Racial and Ethnic Minorities: A Systematic Review
    Journal of General Internal Medicine
    Volume 27, Number 8 (2012), 1033-1046, DOI: 10.1007/s11606-012-2044-2
    Abstract  PDF

    HIV Prevention Interventions to Reduce Racial Disparities in the United States: A Systematic Review
    Journal of General Internal Medicine
    Volume 27, Number 8 (2012), 1047-1067, DOI: 10.1007/s11606-012-2036-2
    Abstract  PDF

    Interventions to Improve Decision Making and Reduce Racial and Ethnic Disparities in the Management of Prostate Cancer: A Systematic Review
    Journal of General Internal Medicine
    Volume 27, Number 8 (2012), 1068-1078, DOI: 10.1007/s11606-012-2086-5
    Abstract  PDF



    2007 Systematic Reviews, Medical Care Research and Review

    Health Disparity: Causes, Consequences, and Change
    Med Care Res Rev 2007 64: 5S -6S.
    PDF

    Marshall H. Chin, Amy E. Walters, Scott C. Cook, and Elbert S. Huang
    Interventions to Reduce Racial and Ethnic Disparities in Health Care
    Med Care Res Rev 2007 64: 7S -28S.
    Abstract  |  PDF

    Andrew M. Davis, Lisa M. Vinci, Tochi M. Okwuosa, Ayana R. Chase, and Elbert S. Huang
    Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions
    Med Care Res Rev 2007 64: 29S -100S.
    Abstract   |   PDF

    Monica E. Peek, Algernon Cargill, and Elbert S. Huang
    Diabetes Health Disparities: A Systematic Review of Health Care Interventions
    Med Care Res Rev 2007 64: 101S -156S.
    Abstrac   |   PDF

    Benjamin W. Van Voorhees, Amy E. Walters, Micah Prochaska, and Michael T. Quinn
    Reducing Health Disparities in Depressive Disorders Outcomes between Non-Hispanic Whites and Ethnic Minorities: A Call for Pragmatic Strategies over the Life Course
    Med Care Res Rev 2007 64: 157S -194S.
    Abstract   |   PDF

    Christopher M. Masi, Dionne J. Blackman, and Monica E. Peek
    Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment among Racial and Ethnic Minority Women
    Med Care Res Rev 2007 64: 195S -242S.
    Abstract   |   PDF

    Thomas L. Fisher, Deborah L. Burnet, Elbert S. Huang, Marshall H. Chin, and Kathleen A. Cagney
    Cultural Leverage: Interventions Using Culture to Narrow Racial Disparities in Health Care
    Med Care Res Rev 2007 64: 243S -282S.
    Abstract   |   PDF

    Alyna T. Chien, Marshall H. Chin, Andrew M. Davis, and Lawrence P. Casalino
    Pay for Performance, Public Reporting, and Racial Disparities in Health Care: How Are Programs Being Designed?
    Med Care Res Rev 2007 64: 283S -304S.
    Abstract   |   PDF

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Systematic Reviews

A Systematic Review of Racial and Ethnic Disparities Intervention Literature

Skip to Articles

Overview

Finding Answers: Disparities Research for Change conducts reviews of racial and ethnic disparities intervention literature to identify successful strategies and provide health care organizations, providers and payers with recommendations on how they can address disparities in their own organizations.

Finding Answers' first set of systematic reviews was published as a special supplement to the October 2007 edition of Medical Care Research and Review: the study reviewed more than 200 articles that outline interventions that have the potential to reduce racial and ethnic disparities in the areas of cardiovascular disease, diabetes, depression and breast cancer.  Additionally, the research surrounding two specific approaches—cultural leverage and pay-for-performance incentives—was examined and provides insight for future intervention development.

Finding Answers' second set of systematic reviews were published as a symposium in the August issue of the Journal of General Internal Medicine. These reviews focused on five additional disease areas: asthma, cervical cancer, colorectal cancer, HIV prevention, and prostate cancer.


Successful Strategies

Through the systematic review, it became clear that the following strategies were often part of successful interventions.

Multifaceted Programs
Successful interventions often involved multiple components targeting different levers of change such as providers, patients, and the community. 

A Focus on Cultural Relevancy
Culturally-tailored quality improvement approaches such as creating intervention materials (posters, pamphlets) with culturally congruent images and in languages other than English produced successful outcomes. The review found that interventions that utilized cultural leverage as a strategy to reduce disparities increased patient knowledge and understanding for self-care, decreased barriers to access, and improved multiple areas of cultural competence for health care providers.

Nurse-led Programs
Nurse-led patient-centered interventions within the context of wider systems change were found to be promising. Because nurses often spend more time with patients and can provide critical care coordination, they are in a unique position to affect change within an organization.

Interactive Education
For programs that utilized education as an intervention strategy, interactive education and skills-based training was found to be more successful than traditional didactic, knowledge-based training.

Family and Community Programs
Patient navigation and interventions that actively involved family and community members in patient care showed promise for improving minority health outcomes.


Key Findings

Key findings from the 2012 reviews of literature in each disease area:

A Roadmap to Reduce Disparities
Five systematic reviews examined interventions to improve minority health and potentially reduce disparities in asthma, HIV, colorectal cancer, prostate cancer and cervical cancer. The five reviews focused on interventions that occur in or have a sustained link to a health care delivery setting, examined racial and ethnic disparities in care and improvements in minority health, rather than geographic, socioeconomic, or other disparities. Based on these reviews, evaluating promising practices, and providing technical assistance to health care organizations, Finding Answers presents a roadmap for reducing racial and ethnic disparities in care. The Roadmap to Reduce Disparities Fact Sheet

Asthma
Authors conducted a systematic review of the literature to characterize interventions with potential to improve outcomes for minority patients with asthma. Overall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. System redesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Asthma Review Fact Sheet

Cervical Cancer
The authors systematically reviewed 31 studies that focused on U.S. racial and/or ethnic minorities who were linked to a health care system. They found that in order to improve the rate of screening for cervical cancer in minority patients, telephone support with navigation and education programs by lay health educators with navigation may be of benefit. In order to improve the diagnosis and treatment of premalignant disease of the cervix, a single visit for screening for cervical cancer and follow-up of an abnormal result may be of benefit, as may telephone counseling. Cervical Cancer Review Fact Sheet

Colorectal Cancer
The authors reviewed 33 studies, from 1950 to 2010, of interventions in U.S. populations eligible for colorectal cancer screening, and composed of greater than 50 percent racial or ethnic minorities. They found that tailored patient education combined with patient navigation services and physician training in communicating with patients of low health literacy can modestly improve adherence to colorectal cancer screening among racial and ethnic minority patients. Looking forward, interventions to improve post-screening follow-up and receipt of life-saving therapy for those diagnosed with colorectal cancer are imperative if we expect the racial and ethnic survival gap to close. Colorectal Cancer Review Fact Sheet

HIV
Authors conducted a systematic review of the past 30 years of HIV prevention interventions addressing racial disparities. They found that an intervention that includes skills-based instruction and is successfully tested in an adolescent population may be adapted for a variety of aims, as long as the core elements of skill-based content and appropriate cultural targeting remain. However, no study was identified that sought specifically to reduce racial disparities in the sexual acquisition of HIV. HIV Prevention Fact Sheet

Prostate Cancer
Twelve of 13 studies that used educational programs, print materials, videotapes/DVDs or the Web for enhancing informed decision making about prostate cancer screening showed statistically significant increases in knowledge. Educational programs showed the greatest percentage increase in knowledge across studies. Of the five cognitive-behavioral interventions reviewed, all improved quality of life among minority men being treated for localized prostate cancer by enhancing problem solving and coping skills. Going forward, a much stronger evidence base for the use of such interventions to improve informed decision making across the clinical spectrum for prostate cancer is essential; especially necessary are more studies that address the role of behavioral interventions to support informed decision making in minority patient coping skills. Prostate Cancer Review Fact Sheet 

 

Key findings from the 2007 reviews of literature in each disease area:

Diabetes
Most of the diabetes intervention literature focused on improvements in health care delivery and outcomes. The researchers found that effective diabetes patient interventions were culturally-tailored. Effective provider interventions incorporated one-on-one feedback and education. Successful health systems interventions effectively engaged nurse case managers and nurse clinicians.

Depression
The literature showed that multi-component chronic disease management interventions have produced improvements in depression outcomes for ethnic minority populations. Case management appears to be a key component of effective interventions and socio-culturally tailored treatment and prevention interventions may be more efficacious than standard treatment programs.

Breast Cancer
A majority of the breast cancer literature involved screening rather than diagnostic testing or treatment interventions. Among patient-targeted screening interventions, those that were culturally tailored or addressed financial or logistical barriers were generally more effective than reminder-based interventions. Chart-based reminders increased physician adherence to mammography guidelines but were less effective at increasing clinical breast examination. Case management was found to be an effective strategy for expediting diagnostic testing after screening abnormalities have been found.

Cardiovascular Disease
This review addressed cardiovascular risk factors (hypertension, hyperlipidemia, physical inactivity, tobacco), and cardiovascular conditions (coronary artery disease ,heart failure). Researchers found that most interventions focus on improving the care of African-American populations, with relatively little work in Hispanic, Asian, and American Indian populations.  Promising interventions for cardiovascular disease include organization level interventions such as registries, interventions involving nurses and pharmacists, contacting patients between clinic visits, and community outreach.


Future Directions

There is still much work to be done in disparities research and in developing effective interventions. Although this review identified several promising strategies that can be built on, it also pointed to the need for additional work and areas where questions still exist.

Moving forward, disparities should be studied in underrepresented populations such as American Indian, Asian American, and pediatric ethnic and geriatric ethnic subgroups. The effect of quality improvement policies, such as pay-for-performance incentives, should be measured to promote a narrowing, as opposed to neutral or widening, effect on disparities. Funding agencies should invest in expanded and coordinated research portfolios to better explain the causes and consequences of health disparities and develop interventions to promote equitable health care and health outcomes. Policy makers should help pave the way to establishing national data structures to monitor the impact of these interventions on the quality of care patients receive.

The United States still has a great distance to travel before racial and ethnic disparities in care can be eliminated.  However, there is reason for optimism based upon the early lessons from the existing literature.   By enhancing knowledge and problem-solving ability in this critical area, practical solutions to end racial and ethnic disparities in health care are possible.


Articles

2012 Systematic Reviews, Journal of General Internal Medicine

A Roadmap and Best Practices for Organizations to Reduce Racial and Ethnic Disparities in Health Care
Journal of General Internal Medicine
Volume 27, Number 8 (2012), 992-1000, DOI: 10.1007/s11606-012-2082-9
Abstract  PDF

Interventions to Improve Outcomes for Minority Adults with Asthma: A Systematic Review
Journal of General Internal Medicine
Volume 27, Number 8 (2012), 1001-1015, DOI: 10.1007/s11606-012-2058-9
Abstract  PDF

Cervical Cancer Screening, Diagnosis and Treatment Interventions for Racial and Ethnic Minorities: A Systematic Review
Journal of General Internal Medicine
Volume 27, Number 8 (2012), 1016-1032, DOI: 10.1007/s11606-012-2052-2
Abstract  PDF

Interventions to Improve Care Related to Colorectal Cancer Among Racial and Ethnic Minorities: A Systematic Review
Journal of General Internal Medicine
Volume 27, Number 8 (2012), 1033-1046, DOI: 10.1007/s11606-012-2044-2
Abstract  PDF

HIV Prevention Interventions to Reduce Racial Disparities in the United States: A Systematic Review
Journal of General Internal Medicine
Volume 27, Number 8 (2012), 1047-1067, DOI: 10.1007/s11606-012-2036-2
Abstract  PDF

Interventions to Improve Decision Making and Reduce Racial and Ethnic Disparities in the Management of Prostate Cancer: A Systematic Review
Journal of General Internal Medicine
Volume 27, Number 8 (2012), 1068-1078, DOI: 10.1007/s11606-012-2086-5
Abstract  PDF



2007 Systematic Reviews, Medical Care Research and Review

Health Disparity: Causes, Consequences, and Change
Med Care Res Rev 2007 64: 5S -6S.
PDF

Marshall H. Chin, Amy E. Walters, Scott C. Cook, and Elbert S. Huang
Interventions to Reduce Racial and Ethnic Disparities in Health Care
Med Care Res Rev 2007 64: 7S -28S.
Abstract  |  PDF

Andrew M. Davis, Lisa M. Vinci, Tochi M. Okwuosa, Ayana R. Chase, and Elbert S. Huang
Cardiovascular Health Disparities: A Systematic Review of Health Care Interventions
Med Care Res Rev 2007 64: 29S -100S.
Abstract   |   PDF

Monica E. Peek, Algernon Cargill, and Elbert S. Huang
Diabetes Health Disparities: A Systematic Review of Health Care Interventions
Med Care Res Rev 2007 64: 101S -156S.
Abstrac   |   PDF

Benjamin W. Van Voorhees, Amy E. Walters, Micah Prochaska, and Michael T. Quinn
Reducing Health Disparities in Depressive Disorders Outcomes between Non-Hispanic Whites and Ethnic Minorities: A Call for Pragmatic Strategies over the Life Course
Med Care Res Rev 2007 64: 157S -194S.
Abstract   |   PDF

Christopher M. Masi, Dionne J. Blackman, and Monica E. Peek
Interventions to Enhance Breast Cancer Screening, Diagnosis, and Treatment among Racial and Ethnic Minority Women
Med Care Res Rev 2007 64: 195S -242S.
Abstract   |   PDF

Thomas L. Fisher, Deborah L. Burnet, Elbert S. Huang, Marshall H. Chin, and Kathleen A. Cagney
Cultural Leverage: Interventions Using Culture to Narrow Racial Disparities in Health Care
Med Care Res Rev 2007 64: 243S -282S.
Abstract   |   PDF

Alyna T. Chien, Marshall H. Chin, Andrew M. Davis, and Lawrence P. Casalino
Pay for Performance, Public Reporting, and Racial Disparities in Health Care: How Are Programs Being Designed?
Med Care Res Rev 2007 64: 283S -304S.
Abstract   |   PDF