Adapting health promotion interventions to meet the needs of ethnic minority groups: mixed-methods evidence synthesis.

BACKGROUND There is now a considerable body of evidence revealing that a number of ethnic minority groups in the UK and other economically developed countries experience disproportionate levels of morbidity and mortality compared with the majority white European-origin population. Across these countries, health-promoting approaches are increasingly viewed as the long-term strategies most likely to prove clinically effective and cost-effective for preventing disease and improving health outcomes in those with established disease. OBJECTIVES 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 healthy eating for African-, Chinese- and South Asian-origin populations. DATA SOURCES Two national conferences; seven databases of UK guidelines and international systematic reviews of health promotion interventions aimed at the general population, including the Clinical Evidence, National Institute for Health and Clinical Excellence and Scottish Intercollegiate Guidelines Network databases (1950-2009); 11 databases of research on adapted health promotion interventions for ethnic minority populations, including BIOSIS, EMBASE and MEDLINE (1950-2009); and in-depth qualitative interviews with a purposive sample of researchers and health promoters. REVIEW METHODS Theoretically based, mixed-methods, phased programme of research that involved user engagement, systematic reviews and qualitative interviews, which were integrated through a realist synthesis. 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, clinical 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. RESULTS 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 interventions with 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. LIMITATIONS The lack of robust evidence of effectiveness for physical activity and healthy-eating interventions in the general population identified at the outset limited the comparative synthesis work we could undertake in the latter phases. Furthermore, the majority of studies undertaking an adapted intervention were conducted within African American populations; this raises important questions about the generalisability of findings to, for example, a UK context and other ethnic minority groups. Lastly, given our focus on three health areas and three populations, we have inevitably excluded many studies of adapted interventions for other health topics and other ethnic minority populations. CONCLUSIONS There is currently a lack of evidence on how best to deliver smoking cessation, physical activity and healthy eating-related health promotion interventions to ethnic minority populations. Although culturally adapting interventions can increase salience, acceptability and uptake, there is as yet insufficient evidence on the clinical effectiveness or cost-effectiveness of these adapted approaches. More head-to-head comparisons of adapted compared with standard interventions are warranted. The Typology of Adaptation, Programme Theory of Adapted Health Promotion Interventions and RESET tool should help researchers to develop more considered approaches to adapting interventions than has hitherto been the case. FUNDING The National Institute for Health Research Health Technology Assessment programme.