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Health care services should be equitable for all. Some immigrant and minority ethnic groups struggle to use these services or adhere to self-treatment in an optimal way. Adapted health information and patient education may benefit these groups. This overview of systematic reviews summarises the effect of such adaptations.
We found high quality systematic reviews about diabetes education, asthma education and cancer screening information. These showed that adapted health information and patient education for immigrant and minority ethnic groups could entail a broad range of interventions of varying intensity. In some studies, the participants received a single culturally adapted education session. Other studies followed up the participants many times, giving them extra care and adapted resources over many months and years.
Most studies were with minority ethnic groups in the USA. Although the US health care system is different from the Norwegian, we consider these results relevant to immigrant and minority ethnic groups in Norway experiencing similar barriers and challenges in using the health care services. Based on the summarised evidence, the anticipated effects of adapted interventions compared to usual care are:
- Adapted diabetes education somewhat improves long-term blood sugar levels in patients. The evidence mainly comes from studies with highly intense interventions.
- Adapted asthma education may give some fewer severe asthmatic exacerbations among children, but the effect is unclear among adults. The evidence comes from studies with interventions of relatively low intensity.
Adapted interventions to promote cancer screening probably increase the number of women attending mammography. The evidence comes from interventions that often involved lay health workers and took place outside the health care sector.
Health care services should be equitable for all. Some immigrant and minority ethnic groups use health care services to a lesser extent, in a different way or have lower compliance with recommend self-treatment than the general population. Limited access to adapted health information and patient education is one possible reason for these patterns. This report gives an overview of summarized evidence on the effect of adapted health information and patient education for immigrants or minority ethnic groups.
This report is an overview of systematic reviews published in 2012 or later. Inclusion criteria were reviews assessing the effects of any adapted health information or patient education compared to usual care or non-adapted information and education. The reviews could include studies with populations of foreign origin, national minorities/minority ethnic groups or indigenous people believed to have specific health problems, limited health literacy skills, language problems or challenges related to optimal use of health care services in their resident country. We searched four electronic literature databases in May 2018. Two researchers independently screened 2689 titles and abstracts, and made final decisions on inclusion based on 55 full text assessments. Eligible systematic reviews were quality assessed and we only report results from high quality reviews. We used the review authors’ analyses and, if available, their assessment of confidence in the evidence of effect for each outcome using the GRADE methodology. Using GRADE, we express our confidence that the estimated effect is close to the anticipated effect of the intervention (the “true effect”) as high, moderate, low or very low for each outcome.
We assessed the methodological quality of 22 systematic reviews that considered the effect of adapted health information or patient education in relation to six health issues or diagnoses: Adapted diabetes education (9 reviews); Adapted asthma education (3 reviews); Adapted information promoting cancer screening (5 reviews); Adapted information/education for diabetes prevention (1 review); Adapted information promoting smoking cessation (1 review); Other types of adapted health information/patient education (3 reviews). Systematic reviews with similar research questions will include the same studies and have overlapping data and findings. We therefore selected one systematic review presenting the evidence best within each health issues or diagnoses.
Thirteen systematic reviews were considered to be of high methodological quality, but these only investigated the three first categories: adapted diabetes education, asthma education and information promoting cancer screening. We present results from one high quality systematic review for each of these categories. Systematic reviews concerning the three next categories were of moderate methodological quality. Notably, these review authors presented results only using statistical significance and direction of effect, without information on the effect size and its uncertainty. For these topics, we present available studies, but no results. The majority of the studies in these systematic reviews were conducted in the USA, most commonly with African Americans and people of Latin American origin. Other studies were from several European countries, Canada, Australia, New Zealand and a few Asian countries, and included a variety of immigrant and minority ethnic groups. All study populations were adults, apart from studies on asthma education, which involved both children and adult patients.
The studies on adapted diabetes education typically entailed a much more intense follow up of the intervention groups than the control groups. Often the participants received several individual or group education sessions, counselling, and telephone follow-up over an average period of 8 months. It is unclear if all the programs had culturally adapted content, and which used another language suiting the participants or bilingual health care personnel. Most studies compared adapted diabetes education to standard diabetes care. The patients had relatively poor blood glucose control before the study. In total, 6536 participants (28 studies) contributed to findings. Based on the summarised evidence, adapted diabetes education somewhat improves long-term blood sugar levels in patients compared to usual care after six months (HbA1c values 0.5% lower, 95% confidence interval (CI) 0.7% to 0.4%, high confidence in the estimated effect); with still somewhat lower HbA1c values after 12 months and possibly after 24 months. It can possibly give patients more knowledge about diabetes and nutrition and higher self-efficacy scores (low confidence in the estimated effect).
The studies on adapted asthma education had interventions of low intensity, varying from only one education session up to three sessions. The interventions seemed to have involved culturally adapted content, but few details were presented. About half of the interventions provided written material using a language suiting the participants or used bilingual health care personnel. The control groups received either conventional asthma education or standard care. In total, 837 participants (7 studies) contributed to the findings. Based on the summarised evidence, adapted asthma education may give some fewer severe asthmatic exacerbations compared to usual care among children (Relative risk 0.48, 95% CI 0.24 to 0.95, low confidence in the estimated effect). The data is too limited to consider likely effect for adults with asthma.
Of the four systematic reviews of high methodological quality, we present results from one concerning adapted information about mammography for Hispanic women in the USA. The interventions in these studies generally used lay health workers from the same culture to deliver educational sessions, outreach to women on arenas outside the health sector and mobile screening units offering free screening. The control group received no specific interventions. In total, 2343 participants (5 studies) contributed to the findings. Based on the summarised evidence, adapted interventions to promote cancer screening probably increase the number of women attending mammography after 6-12 months (Odds ratio 1.67, 95% CI 1.24 to 2.26, moderate confidence in the estimated effect). The three other high quality systematic reviews on this topic concerned adapted information on screening for different types of cancers (cervix, colorectal and prostate), interventions targeting other minority ethnic groups (minorities in the USA) and men. The results indicate from little or no difference to a moderately higher adherence to cancer screening programs, when participants receive adapted information.
The systematic reviews on adapted health information for diabetes prevention, smoking cessation and some other health concerns were all of moderate methodological quality. The reviews did not summarise the pooled effects of these interventions. We still chose to give a brief presentation of the reviews in this report to indicate the considerable number of primary studies available on these topics.
Most of the studies in the included reviews concerned African American and people of Latin American origin with low socioeconomic status in the USA. A high proportion of these participants have likely no or poor health insurance. There are fewer studies of adapted interventions for other immigrant and minority ethnic groups and from countries with other health care systems. However, the defined study population in this overview relates to patient groups “under-using” or having specific challenges regarding use of the health care services. We therefore consider the results relevant to immigrant and minority ethnic groups experiencing similar barriers and challenges in using the health care services, but not all immigrants and minority ethnic groups per se.
The terms “adapted health information” and “adapted patient education” comprises a wide range of activities and intensities of interventions. The interventions in these reviews were generally complex, often including a substantial increase in the number of interactions the participants had with the health care services. Common activities were individual or group education sessions, extra counselling, or telephone support, and not only linguistic or direct cultural adaptations.
The included systematic reviews gave limited descriptions of what the cultural adaptations entailed. In particular, the reviews give little insights into the use of learning aids (for instance pictures, movies, and comics) and if the interventions adapted the messages to deeper cultural characteristics of the target population. Many studies had intervention components that are not strictly adhering to cultural needs, but rather financial, structural, social or educational barriers to accessing appropriate health care. Examples are providing free access to mammography services or giving health information in people’s homes or on arenas outside the health care sector. Since many of the interventions were intense with several different components given together, we do not know which elements are most influential or necessary for achieving the effects.
It seems that intense interventions with adapted health information and patient education can improve health measures somewhat among vulnerable immigrant or minority ethnic groups.