Disparities in smoking: data from the Nashville REACH 2010 project

How can additional secondary data analysis of observational data enhance the generalisability of meta-analytic evidence for local public health decision making?

This paper critically explores how survey and routinely collected data could aid in assessing the generalisability of public health evidence. We propose developing approaches that could be employed in understanding the relevance of public health evidence, and investigate ways of producing meta-analytic estimates tailored to reflect local circumstances, based on analyses of secondary data. Currently, public health decision makers face challenges in interpreting global review evidence to assess its meaning in local contexts. A lack of clarity on the definition and scope of generalisability, and the absence of consensus on its measurement, has stunted methodological progress. The consequence of failing to tackle generalisability means that systematic review evidence often fails to fulfil its potential contribution in public health decision making. Three approaches to address these problems are considered and emerging challenges discussed: (1) purposeful exploration after a review has been conducted, and we present a framework of potential avenues of enquiry and a worked example; (2) recalibration of the results to weight studies differentially based on their similarity to conditions in an inference population, and we provide a worked example using UK Census data to understand potential differences in the effectiveness of community engagement interventions among sites in England and Wales; (3) purposeful exploration before starting a review to ensure that the findings are relevant to an inference population. The paper aims to demonstrate how a more nuanced treatment of context in reviews of public health interventions could be achieved through greater engagement with existing large sources of secondary data.

Working to Eliminate Cancer Health Disparities from Tobacco: A Review of the National Cancer Institute's Community Networks Program

INTRODUCTION

In 2005, the National Cancer Institute funded the Community Networks Program (CNP), which aimed to reduce cancer health disparities in minority racial/ethnic and underserved groups through community-based participatory research, education, and training. The purpose of this study was to describe the CNP model and their tobacco-related work in community-based research, education, and training using a tobacco disparities research framework.

METHODS

We conducted a comprehensive review of the CNP tobacco-related activities including publications, published abstracts, research activities, trainee pilot studies, policy-related activities, educational outreach, and reports produced from 2005-2009. Two authors categorized the tobacco-related activities and publications within the framework.

RESULTS

Although there was no mandate to address tobacco, the CNPs produced 103 tobacco-related peer-reviewed publications, which reflects the largest proportion (12%) of all CNP cancer-related publications. Selected publications and research activities were most numerous under the framework areas "Psychosocial Research," "Surveillance," "Epidemiology," and "Treatment of Nicotine Addiction." Thirteen CNPs participated in tobacco control policymaking in mainstream efforts that affected their local community and populations, and 24 CNPs conducted 1147 tobacco-related educational outreach activities. CNP activities that aimed to build research and infrastructure capacity included nine tobacco-related pilot projects representing 16% of all CNP cancer-related pilot projects, and 17 publications acknowledging leveraged partnerships with other organizations, a strategy encouraged by the CNP.

CONCLUSIONS

The CNP is a promising academic-community model for working to eliminate tobacco-related health disparities. Future efforts may address scientific gaps, consider collaboration across groups, assess the extent of operationalizing community-based participatory research, and improve common tracking measures.

Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations

BACKGROUND

Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models.

OBJECTIVES

To assess effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

SEARCH METHODS

We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index, Dissertation Abstracts, System for Information on Grey Literature in Europe (SIGLE) (from January 1990 through September 30, 2013), and Global Health Library (from January 1990 through March 31, 2014).

SELECTION CRITERIA

Cluster-randomized controlled trials, randomized controlled trials, quasi-experimental designs, controlled before-after studies, interrupted time series studies, and prospective controlled cohort studies. Only studies of community coalitions with at least one racial or ethnic minority group representing the target population and at least two community public or private organizations are included. Major outcomes of interest are direct measures of health status, as well as lifestyle factors when evidence indicates that these have an effect on the direct measures performed.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each study.

MAIN RESULTS

Fifty-eight community coalition-driven intervention studies were included. No study was considered to be at low risk of bias. Behavioral change outcomes and health status change outcomes were analyzed separately. Outcomes are grouped by intervention type. Pooled effects across intervention types are not presented because the diverse community coalition-led intervention studies did not examine the same constructs or relationships, and they used dissimilar methodological designs. Broad-scale community system level change strategies led to little or no difference in measures of health behavior or health status (very low-certainty evidence). Broad health and social care system level strategies leds to small beneficial changes in measures of health behavior or health status in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions led to beneficial changes in health behavior measures of moderate magnitude in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions may lead to beneficial changes in health status measures in large samples of community residents; however, results were not consistent across studies (low-certainty evidence). Group-based health education led by professional staff resulted in moderate improvement in measures of health behavior (very low-certainty evidence) or health status (low-certainty evidence). Adverse outcomes of community coalition-led interventions were not reported.

AUTHORS' CONCLUSIONS

Coalition-led interventions are characterized by connection of multi-sectoral networks of health and human service providers with ethnic and racial minority communities. These interventions benefit a diverse range of individual health outcomes and behaviors, as well as health and social care delivery systems. Evidence in this review shows that interventions led by community coalitions may connect health and human service providers with ethnic and racial minority communities in ways that benefit individual health outcomes and behaviors, as well as care delivery systems. However, because information on characteristics of the coalitions themselves is insufficient, evidence does not provide an explanation for the underlying mechanisms of beneficial effects. Thus, a definitive answer as to whether a coalition-led intervention adds extra value to the types of community engagement intervention strategies described in this review remains unattainable.

A review of tobacco use treatments in U.S. ethnic minority populations

BACKGROUND

Tobacco use is the leading preventable cause of disease and death in the United States. Among racial and ethnic minorities, disparities in tobacco use, knowledge of health risks and treatment resources, and access to and utilization of treatment contribute to a disproportionate disease burden from tobacco use. Furthermore, racial and ethnic minorities have been underrepresented within tobacco treatment studies.

PURPOSE/OBJECTIVE

This paper provides a review of published studies examining tobacco treatment interventions among ethnic and minority populations in the United States.

STUDY DESIGN/METHODS

Literature searches were used to identify smoking cessation interventions involving racial/ethnic minority populations. Identified studies were published between 1985 and 2009 involving African-American, Latino, Native American, and Asian or Pacific Islander smokers. Studies included in the review (1) targeted one or more ethnic minority group or had at least 10% of study participants from ethnic minority groups and (2) reported abstinence outcomes.

RESULTS

Sixty-four studies were included in this review. Of studies meeting inclusion criteria, 28 included a primary focus on African-Americans, 10 focused on Latinos, 4 focused on Native Americans, and 3 focused on Asian-American smokers. An additional 19 studies reported samples including participants from more than one minority group. Sample inclusion criteria, intervention content and duration, follow-up, abstinence assessment, and limitations of these studies were reviewed.

CONCLUSIONS

Individuals from racial and ethnic minority populations are interested in stopping smoking and willing to participate in treatment research. Variations in the content of treatment intervention and study design produced a range of abstinence outcomes across studies. Additional research is needed for all groups, including African-American smokers, and special attention is warranted for Latino, Native American, and Asian groups given the paucity of published studies. Although there were limited evaluations of pharmacotherapy, the existing data support use of pharmacotherapy in addition to counseling for enhancing abstinence outcomes. Further attention to level of individual smoking, variability in smoking patterns, and use of other tobacco products is needed, given known variation within and between racial and ethnic groups. Overall, findings are consistent with recommendations from the 2008 Clinical Practice Guidelines calling for increased research devoted to evaluating and enhancing tobacco use treatment interventions among racial and ethnic minority populations.

Trends in smoking among African-Americans: a description of Nashville's REACH 2010 initiative

African Americans bear a disproportionate burden of tobacco related morbidity and mortality despite smoking less than their Caucasian counterparts. Nashville's REACH 2010 initiative developed community partnerships to promote awareness, education and participatory programs to prevent and decrease smoking among residents of the northern geographic area of Nashville, TN, a majority African American community. A social-ecological model provided the framework for interventions used during a 5 year period that included: (a) community level strategies to increase awareness and knowledge about the effects of smoking; (b) individual level strategies to enlist and train community members to become advocates, lead smoking cessation classes and encourage current smokers in quit attempts; and (c) strategies directed to changing policy through education and partnership building. Smoking prevalence among residents was examined from 2001 through 2005 based on data from the Nashville CDC REACH 2010 Risk Factor Survey and the Tennessee CDC Behavioral Risk Factor Survey. Tests for linear trends indicated a significant decreasing trend (P < .02) of daily smoking and smoking uptake (P < .03) in North Nashville. In contrast to our community an increasing trend was observed in quitting smoking (P < .01). No trends were significant for African Americans in Tennessee. This study suggests that consistent, multiple and multi-level strategies targeted to an African American community may impact smokers who are not ready to quit but willing to reduce their level of smoking. This study underscores the importance of developing and implementing community wide campaigns to address the needs of African Americans.