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					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
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 •     Tailored interventions,
  involve messages that        involve messages that
  are intended to reach        are intended to reach
  population subgroups         an individual based on
  based on a specific set of   specific characteristics
  shared 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
• 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
    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
                           Health Revitalization
                           Act of 1993 establishes
                           the Office of Research
                           on Minority Health
1972             1985
                 DHHS Heckler                              2003 IOM Report “Unequal
                 Report on Black                           Treatment” and first
Syphilis Study
                 and Minority                              National Healthcare
becomes public
                 Health                                    Disparities Report published

1970       1980            1990                  2000              2007          2010
Expansion of Cultural Competence
              Early models       Newer models
              (cross-cultural)   (Cultural Competence)
Populations   Immigrants,        All people of color, other
              refugees           disadvantaged groups
                                 (those affected by health
Concepts      Culture,           Culture, Language,
              Language           Prejudice, Stereotyping,
                                 Social Determinants of
Scope         Interpersonal      Health Care Systems,
              interactions       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
• 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

  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
                                       Culturally       cultural differences to build
 organization to meet
                                   Competent Health       an effective relationship
 needs of diverse groups
                                     Care Systems           with a patient:
 of patients:
• Diverse workforce                                              • Understands the meaning
  reflecting patient                                               culture
  population                                                     • Is knowledgeable about
• Facilities convenient to                                         different cultures
                                       Culturally                • Appreciates diversity
  community                           Competent
• Language assistance for                                       • Is aware of health
  patients with limited
                                     Health Care                  disparities and
  English proficiency                Interactions                 discrimination affecting
• Staff training regarding                                        minority groups
  delivery of culturally and                                    • Effectively uses interpreter
  linguistically appropriate                                      services when needed
• Culturally appropriate
  health education                             Saha S, Beach MC, Cooper LA.
  materials                                    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        Attitudes toward
   Race, Ethnicity         Effectiveness
   Gender, Age,                                      Treatment
   Education                 Medications             acceptability
                                                                                 Behavioral           Behavior
   Illness                                                                       Intention
   variables                 Prayer
                                                                                 Plans to seek help   treatment
                           Perceived need
                           Value of outcome
                          Normative beliefs          Subjective norms
                          Family would be            Employer stigma
   Social Support         disappointed               Friend stigma
   Life Events

                     Modified from The Theory of Reasoned Action (Azjen, 1996)
Sample Comments Made by Patients
   in Depression Focus Groups

  “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

   “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

    Cooper LA et al, Journal of General Internal Medicine 2001;16:634-638
Views about depression differ among
   Whites, Blacks, and Hispanics
                                             White Blacks Hisp
                                             n=659 n=97 n=72
I believe I need treatment                     68    70    68
Medications are effective                      91    69    84 †
Medications are addictive                      34    56    51 **
Counseling is as effective as meds             50    57    74 **
Counseling brings up bad feelings              50    71    71 **
Prayer heals depression                        67    93    67 †
Socially embarrassed                           24    24    33
Family would be disappointed                   16    15    22
Prefer same ethnicity/race provider            14    25    13 *
*p<0.05, **p<0.01, †p<0.001   Cooper LA et al. Med Care 2003;41:479-489
     Physicians engage in less
depression talk and rapport-building
 with depressed African Americans

                       P=0.30             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                              Sample Comments
Most effective parts of the“I think having real people with real
videotape                  problems was effective.”
Ways to improve the        “It would have been more effective if
videotape                  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          Sample Comments
Race,          “I‟ve never really paid much attention to videos in
ethnicity      the past because they mainly had Caucasians that I
and cultural   couldn‟t really relate to, and to sit here and watch
issues         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
               “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     “I was surprised to see so many men [in the
stereotypes    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                       Patient-Centered
           Intervention                           Intervention
             Providers                              Patients*
               N=15                                  N=125

Provider Recruitment              Patient Recruitment

             Standard                               Standard
           Intervention                           Intervention
             Providers                              Patients*
               N=15                                  N=125

    *DCM contacts for active follow-up up to 12 months
     Bridge Study Primary Care
    Clinician Intervention Features
Intervention                 Standard       Patient-
                           Intervention     Centered
Two academic detailing          X              X
visits (CME credit)
Psychiatric consultation        X              X
liaison support
Communication skills                           X
on interactive CD-ROM
Culture-specific                               X
Examples of Clinician Goals

           • Improve recognition
           • Evaluate associated conditions
           • Assess suicidal ideation
           • Change usual antidepressant
           • Identify patients‟ cultural
           • 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       Patient-
                                          Intervention     Centered
Needs Assessment                               X
Patient Centered Needs Assessment                             X
Education and Activation                       X              X
Social support/informal counseling             X              X
Standard education materials                   X
Culturally targeted education materials                       X
Black Mental Health Alliance List                             X

Cultural information packet for MH                            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

   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

*only   if patient is spiritually oriented and/or receptive
          Patients rated the patient-
          centered depression care
          manager as more helpful

 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
• 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?

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