Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program 

Interventions to Improve 

Minority Health Care 

and Reduce Racial 

and Ethnic Disparities

Department of Veterans Affairs

Health Services Research & Development Service

September 2011

Investigators:

Principal Investigator:

Ana R. Quiñones, PhD

Co-Investigators:

Maya O’Neil, PhD

Somnath Saha, MD

Michele Freeman, MPH

Stephen R. Henry, DrPH, MPH

Devan Kansagara, MD, MCR

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Portland VA Medical Center

Portland, OR

Devan Kansagara, MD, MCR, Director
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PREFACE

Health Services Research & Development Service’s (HSR&D) Evidence-based Synthesis 

Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare 

topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout the VA.

HSR&D provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient outcomes 

and to support VA clinical practice guidelines and performance measures, and 

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of HSR&D field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Quiñones AR, O’Neil M, Saha S, Freeman M, Henry S, Kansagara D. 

Interventions to Reduce Racial and Ethnic Disparities. VA-ESP Project #05-225; 2011

This report is based on research conducted by the Evidence-based Synthesis Program 

(ESP) Center located at the Portland VA Medical Center, Portland OR funded by the 

Department of Veterans Affairs, Veterans Health Administration, Office of Research 

and Development, Health Services Research and Development. The findings and 

conclusions in this document are those of the author(s) who are responsible for its 

contents; the findings and conclusions do not necessarily represent the views of the 

Department of Veterans Affairs or the United States government. Therefore, no statement 

in this article should be construed as an official position of the Department of Veterans 

Affairs. No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock ownership or options, expert testimony, grants or patents 

received or pending, or royalties) that conflict with material presented in the report.
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EXECUTIVE SUMMARY

BACKGROUND

Racial and ethnic disparities are widespread in the US health care system. A 2007 report from the 

Veterans Affairs (VA) Health Services Research & Development Service (HSR&D) Evidencebased Synthesis Program (ESP) found disparities were prevalent in a variety of clinical arenas 

within the Veterans Affairs health care system. The report identified several promising avenues 

for future interventions designed to reduce racial and ethnic disparities. 

The objectives of this review are to describe the state of disparities intervention research within 

the VA, glean lessons from systematic reviews of intervention research not limited to VA settings, 

and develop an organizing framework to describe studies in this field of research. This report is 

also intended to inform future disparities intervention research in the VA, as well as VA policies 

and programs to reduce disparities.

To accomplish these objectives, we will answer the following key questions:

Key Question #1. What is the state of research on interventions to reduce race/ethnic disparities 

or to improve health and health care in minority populations within VA health care settings?

Key Question #2. What are the results of interventions (within and outside the VA) to reduce 

race/ethnic disparities or to improve health and health care in minority populations?

METHODS

We conducted a search for recent primary intervention studies of VA patients in MEDLINE®

(PubMed®) (2006 through August 2010) using the search strategy developed for the 2007 VAESP report on health disparities. We also conducted a follow-up search for recently published 

studies by investigators conducting current research during the time of the 2007 report. Due 

to the large amount of literature on race/ethnic intervention studies conducted outside VA 

settings, we conducted a search for systematic reviews of intervention studies not limited to VA 

patients in MEDLINE® (PubMed®), the Cochrane Database of Systematic Reviews (OVID), 

and PsycINFO® (OVID) (database inception through November 2010). We obtained additional 

articles from reference lists of pertinent studies. Additional articles were obtained through 

reviewer feedback following review of the initial draft of this report. 

Two reviewers assessed the titles and abstracts identified by the literature search for relevance 

to the key questions. Two reviewers independently reviewed the articles for inclusion, and 

discordant results were resolved through discussion and input from a third reviewer. We included 

studies evaluating the effects of an intervention within (single-race) or between racial/ethnic 

groups (comparative). We relied on systematic reviews and meta-analyses of intervention studies 

conducted outside the VA setting (inclusion/exclusion criteria provided in Appendix B). We 

excluded poor quality reviews as defined by previously developed criteria (Appendix C). 
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RESULTS

The search for systematic reviews yielded 2,127 citations, and the search for primary VA studies 

published since the 2007 report yielded 1,290 citations. Following a review of these 3,417 titles 

and abstracts, we selected 115 articles for further review at the full-text level. We organized the 

literature addressing key question #1 and key question #2 according to clinical or substantive 

topic area.

SUMMARY OF FINDINGS

Key Question #1. What is the state of research on interventions to reduce race/

ethnic disparities or to improve health and health care in minority populations 

within VA health care settings?

We found five recently published primary studies of interventions involving minority Veteran 

populations.1-5 The populations included in these studies varied. Two were comparative and 

included black and white Veterans.1, 5 Another two studies were comparative with black, white 

and Hispanic Veteran populations.2, 4 The final study was single-race and examined Native 

American Veterans.3

The effectiveness of the interventions examined by these studies also varied. Only one of the 

studies examined is able to conclude that the intervention significantly reduced disparities.4

 One 

of the studies did not examine the effects of the intervention by race group,1 one study piloted the 

acceptability of the intervention in the minority population without evaluating the effects on the 

outcome,3

 one study found reductions in disparities in intermediate outcomes only5 and the final 

study concluded that no significant findings were attributable to the intervention.2

Key Question #2. What are the results of interventions (within and outside the VA) 

to reduce race/ethnic disparities or to improve health and health care in minority 

populations?

The results from systematic reviews of interventions conducted in settings not limited to the VA 

are summarized by clinical area below:

Diabetes Interventions

Five good quality systematic reviews of interventions for diabetes mellitus identified studies that 

were mostly conducted in single-race populations. We also identified one primary intervention 

study tested on a multiethnic population of Veterans. There was some evidence of benefit for 

interventions focused on community health workers, care managers, and culturally tailored 

health education for patients. Provider-focused interventions reported improvements in process 

measures, although computerized reminders for physicians resulted in negligible or negative 

results. Studies on the long-term effects of diabetes mellitus interventions on process and 

outcome measures are lacking. Heterogeneity between studies in subjects, settings, study design, 

and multiple aspects of the interventions limit the comparisons that can be made across studies. 

One small single center VA study suggests a telemedicine/care coordination intervention may 

reduce disparities in black Veterans with diabetes; this finding warrants further research. 
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Arthritis and Pain Management Interventions

Our search identified one fair quality systematic review examining the effects of behavioral 

interventions for arthritis in minority and white populations. We also identified one primary 

study of VA patients evaluating the effects of a decision aid on expected postoperative total knee 

replacement pain and function levels. The systematic review of behavioral interventions for 

arthritis found limited evidence from two randomized controlled trials that exercise interventions 

may be effective in improving differences in pain and disability between white and black 

patients. In addition, one primary VA study investigating an educational intervention provides 

evidence of improving knowledge and expectations related to total knee replacement for black 

patients; however, willingness to consider total knee replacement surgery did not change among 

either whites or blacks. There remains a need for interventions designed to measure and reduce 

disparities in the burden of osteoarthritis outcomes. 

Preventive and Ambulatory Care Interventions

We identified the greatest number of reviews in preventive and ambulatory care interventions. 

Fourteen good quality reviews of single-race and comparative studies encompassed several 

preventive health subtopics, including cancer screening, smoking cessation and physical activity 

and diet. Little research focused on reducing gaps in screening, treatment and outcomes for 

minority compared to white adults. Several reviews noted the lack of sufficient number of 

studies to compare similarly configured interventions or specific components of multifaceted 

interventions. There is some evidence that community health workers may improve rates of 

preventive health service utilization. Overall, improvements in preventive and ambulatory care 

for minorities are inconsistent. The overwhelming majority of reviews focused on improving 

screening and process of care measures for race/ethnic minorities; there is less research 

evaluating the effects of interventions on health outcomes.

Cardiovascular Disease Interventions

We identified three systematic reviews that examined cardiovascular health care interventions. 

Most studies were conducted in single-race populations and could not test the ability of 

interventions to reduce disparities. Those comparative studies with mixed populations did 

not test for differential intervention effects based on race/ethnicity. The largest body of 

literature focused in the areas of hypertension and smoking cessation. On the whole, nursebased interventions were associated with improvements in proximal health outcomes (e.g., 

blood pressure, lipid level, body mass index) for minority populations, but the addition of 

community health workers provided limited gains. Culturally tailored education approaches to 

lifestyle change interventions appear promising. Several small trials suggest intensive nurse-led 

multicomponent care management interventions may reduce hospitalization in minority patients 

with heart failure. 

HIV/AIDS Interventions

We identified four good quality comparative and single-race systematic reviews (meta-analyses) 

that examined the effectiveness of behavioral interventions for HIV and sexually transmitted 

infection risk reduction among African Americans and Hispanic Americans. No intervention 

studies were specifically designed to reduce disparities. However, evidence suggests that 

behavioral interventions can be effective in improving HIV/AIDS service utilization and health 
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care outcomes for African American and Hispanic American populations. A number of studies 

consistently found that behavioral interventions can reduce risky sex behavior and sexually 

transmitted infection rates. In particular, gender and culture-specific interventions focused on 

empowerment were effective in at-risk African American female populations. The reviewed 

studies did not address organizational barriers and only targeted behavioral intervention efficacy. 

No studies focused on reducing disparities among Veterans.

Mental Health Interventions

We identified two good quality systematic reviews examining interventions aimed at reducing 

disparities in mental health care in settings not limited to the VA. Additionally, we found two 

primary studies conducted within VA settings that addressed mental health care disparities. There 

is good evidence suggesting that multicomponent chronic disease management interventions 

including case management strategies and care coordination are helpful in reducing health 

disparities related to depression. There is insufficient research investigating the effectiveness 

of culturally tailored psychotherapeutic and preventive interventions in reducing disparities 

in depression; however, the preliminary evidence in this area indicates that these types of 

culturally tailored interventions hold promise. No good quality primary studies designed to 

compare disparities before and after interventions in Veteran populations were identified; 

however, two primary studies provide some support for the feasibility of using technology-based 

interventions with ethnic minority Veteran populations. There were no good quality reviews 

examining disparities reduction interventions for mental health conditions other than depression. 

There is insufficient evidence for psychopharmacological, psychotherapeutic, and preventive 

interventions in ethnic minority populations. Preliminary research suggests such interventions 

can be effective, particularly when they are culturally tailored and include a care coordination or 

case management component.

Cross-Cutting Interventions

We found five good quality reviews conducted in settings not limited to the VA, as well as 

one primary VA study of interventions that cut across clinical categories. Of the five reviews, 

four focus on cultural competence training interventions and one focuses on interventions to 

improve quality of care delivered in primary care settings. One VA study examined the effects 

of home-based primary care on improving outcomes for minority Veterans with multiple chronic 

conditions. No primary studies on cultural competence with VA populations were identified. 

There is good evidence that cultural competence interventions can improve provider knowledge, 

attitude, and skills, but there are few good quality studies of effects on patient outcomes. 

Overall, interventions designed to improve the delivery of care for all patients are effective; 

however, most studies of interventions to reduce disparities between minority and white patients 

are characterized by poor quality. One small single-site VA study provides very limited initial 

evidence that care coordination and multiprofessional home-based primary care programs can 

improve process of care measures for an African American cohort.

Summary of Results across Interventions 

Examination of reviews not limited to VA populations as well as primary VA studies points 

toward comprehensive interventions garnering more promising results. Although not directly 

comparable, there were some similar intervention types implemented across clinical areas 
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included in this review. Based on our review, interventions that include personnel (e.g., care 

managers, community health workers) providing increased connectedness between patients and 

the health care systems they access offer indications of effective intervention results. Though 

the strength of evidence is limited by methodological issues, small sample sizes, and the 

preponderance of studies focused on non-VA populations, the most promising interventions in 

the various clinical areas reviewed were care coordination, care management, community health 

workers and culturally tailored education interventions. However, it is interesting to note that at 

least one review of interventions to reduce HIV/AIDS found that efficacious interventions did 

not use peer outreach. 

DISCUSSION

State of Intervention Research

The intent of this review was to take stock of evidence provided by VA intervention studies 

designed to reduce race/ethnic disparities among minority Veteran populations. However, few 

published interventions in VA settings were found in our systematic searches. As a result, we 

examined intervention studies not exclusive to VA populations because many of the interventions 

studied – outside of those focused on organizational change in non-integrated health systems 

– could be potentially informative to VA settings. In general, these reviews from disparate 

clinical and cross-clinical areas find that a good case can be made for interventions based on 

case manager-led care coordination efforts, culturally tailored education, and community health 

workers. However, most interventions were implemented in minority populations only, without 

a comparison group to determine if the interventions were reduced disparities between minority 

and white patients. 

Our review offers the opportunity to categorize existing disparities research in order to highlight 

gaps in the literature and provide a framework for describing future interventions. Based on our 

review, we categorized disparities intervention research studies according to the populations 

included. Most studies included single-race or minority-only populations, examining the effect 

of interventions within a group known to receive lower quality care or have poorer outcomes 

than the majority white population. Effectiveness documented in such studies provides only 

indirect evidence that the studied intervention will reduce disparities. Fewer studies were 

comparative in nature, including both minority and majority populations and comparing 

measures in both groups before and after the intervention. Such studies provide direct evidence 

of an intervention’s capacity to reduce disparities. However, studies including minority and 

majority groups did not always report data stratified by race/ethnicity. 

We also categorized interventions, as “generic” or “tailored”. The bulk of included studies 

described generic interventions, ones that are applied without consideration of group specific 

needs or preferences. Many of these interventions involved quality improvement efforts or care 

standardization testing the premise that deficits in care for minority groups might be reduced 

if care was applied similarly to everyone. In contrast, tailored interventions describe efforts to 

address barriers specific to a minority group. Many of these interventions involved specially 

designed educational materials crafted with specific minority groups in mind (e.g., lessons that 

address knowledge and health beliefs of minority populations), or community health workers 

that addressed the special needs of minority patients within their own communities. Community 
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health workers were typically members of those minority communities and therefore understood 

the context and culture of the population served.

Conceptual Framework

Though the evidence base is overall a limited one, there are common intervention types across 

clinical areas that suggest promising results. Studies that considered patients in their lived 

environment were often more promising than those focused strictly on care delivered within 

health systems. This finding suggests that a framework incorporating home and community 

context, and the social determinants of health and illness can provide a useful way of thinking 

about effective interventions to reduce disparities. In this view, race/ethnic disparities in health 

are seen as driven in part by a broad array of social factors—ranging from education, poverty, 

and community infrastructure—as well as a complex interplay between these social influences, 

characteristics of communities and environments where individuals reside, and interactions with 

providers and health care systems. 

Reducing disparities in the care and outcomes of minority Veterans poses special challenges 

that may require integrating medical care and public health interventions, and linking health 

systems to communities. Despite operating under an integrated health care system with universal 

access for Veterans, race/ethnic disparities in care and outcomes remain prevalent in VA settings. 

Reducing disparities in health care and outcomes will require not only improving equity within

the health care system but extending beyond the system and into the communities where patients 

live and work. Health care, in other words, may need to incorporate an understanding of the 

social determinants of health and extend beyond health care facilities into patient communities. 

Such an approach is in line with current efforts to make the delivery of health care more patientcentered.

Future Research and Implications for VA Health Care Settings

There are several key steps that may aid in the development, testing, and implementation of 

disparities interventions that could help fill some of the many identified evidence gaps. First and 

foremost, continuing the VA policy to consistently collect race and ethnicity information for all 

Veterans is to be encouraged. The ongoing concerted effort to populate race/ethnicity in the VA 

data records is a critical step to chronicling progress in reducing disparities for minority Veterans. 

In addition, there are practical and operational considerations to implementing promising 

interventions. Identifying optimal characteristics for these interventions is necessary for effective 

implementation. For example, the use of community health workers was frequently identified 

as a strategy that holds promise for reaching minority populations. However there is substantial 

heterogeneity in the composition, training, monitoring, frequency of contact and setting 

for peer health workers. Identifying optimal characteristics (e.g., training protocols, forms, 

software) for these interventions is necessary for effective implementation. Documentation and 

implementation details (including unanticipated challenges and solutions) should be encouraged. 

In sum, in order to translate promising directions posed in this review into future research and 

implementation efforts in the VA, it is necessary to consider the following issues:

• Describe interventions in more detail in order to allow for determination of 

effective components of interventions. For example, in interventions involving 
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community health workers and care managers, there was poor specification of the 

training of those personnel. 

• Integrate the use of community health workers into VA settings. This could involve 

Veteran peer advisors coming from communities where Veterans reside. 

• Examine the potential for ongoing large VA demonstration projects in care 

coordination/care management to improve the health of minority Veterans and 

reduce disparities.

• Enhance the capacity to tailor patient educational materials to address the specific 

needs of minority Veterans.

• Consider funding studies explicitly designed to measure pre-post changes in 

disparities between minority and white Veterans.

• Encourage the inclusion of less well studied minority Veteran groups (i.e., Asian/

Pacific Islander and American Indian) in the design and implementation of 

disparities studies. 

Few disparities interventions have been implemented in the VA, and although a few race-specific 

intervention studies are underway, much more work is needed in this area. The barriers to 

implementing disparities intervention research in VA care settings are not entirely clear. Future 

steps emanating from this review will include conducting a survey and interviews of key VA 

informants to identify barriers to dissemination of interventions, in an effort to provide a better 

understanding of the obstructions in the VA disparities research pipeline.