Bridging the multicultural gap

Editor’s note: Valerie Berman is partner/qualitative consultant at Market Segment Research Inc., Coral Gables , Fla.

While life expectancy and overall health have improved in recent years for most Americans, health disparities that occur by race and ethnicity are persistent. The Centers for Disease Control and Prevention remind us that, for many Americans, “…good health is elusive, since appropriate care is often associated with an individual’s socioeconomic status, race, and gender.” Demographic trends point to the continued increase in these disparities as the groups with poorer health status grow in relation to the larger population.

Can consumer research play a role in helping to reduce these health disparities? My experience conducting qualitative studies for pharmaceutical and health services companies has demonstrated the potential for consumer insight to make a difference in the way public education campaigns and health-related marketing initiatives are designed and delivered. Indeed, I believe that sustained information-gathering efforts that raise our awareness of cultural barriers and possible facilitators to better health can play a key role in addressing knowledge gaps among policy makers, marketers and other stakeholders in the multicultural health divide.

This article will address themes and recommendations for conducting successful health care projects among multicultural populations.

Illustrate the challenges

What are some of the themes that have consistently emerged in qualitative studies of multicultural health care? The vignettes that follow illustrate just a few of the challenges around health care issues.

An African-American head of household has been instructed by her husband’s physician to radically alter her cooking methods, including cutting out fried foods, favorite meats and eliminating her tasty cooking oils. Still, she must prepare food for the rest of the household members, who don’t want to participate in “the new way.” Her husband has been diagnosed with cardiovascular disease and it is up to her to institute changes in his diet now. While she is up to the task, her cherished recipes handed down by tradition will suffer the ax as well.

Theme: The burden of change causes tension, anxiety and loss of freedom for patients and families. Chronic illness has deep sociocultural implications. Disease becomes a family issue, one that touches not only palates but emotions as well. When a way of life, in part defined by diet, is threatened, families are forced to redefine tradition.

A Colombian-born patient with diagnosed high cholesterol files away her statin prescription in favor of eggplant water, a home-based remedy popular among Caribbean-basin populations. She is terrified of medicines that “cure one thing but damage another,” and is convinced that these medications will damage her liver - she has heard so on TV. Her erroneous interpretation of side effects keeps her from taking medication that could potentially save her life.

Theme: Myths about drug side effects are significant barriers to compliance with physician-prescribed therapeutic plans. Consumers act on fragmented information or on strongly-held beliefs about the effects of long-term medication use on their bodies. In many cases, they opt to self-dose or to halt treatment when they perceive their symptoms have dissipated.

Subplot: Home-based remedies considered “natural” are often preferred over prescriptions as ways to combat illness. Language barriers contribute to the lack of accurate information.

An adult Puerto Rican asthma sufferer seldom leaves his home for fear of needing rescue medication that has become increasingly costly. He can’t afford maintenance therapy. As a result, he is suffering from depression. Environmental factors in his building, however, contribute to the vicious cycle of his disease.

Theme: Socioeconomic factors contribute to poor health and, ultimately, to compounded health problems. Isolation and fear caused by chronic illness create a dual burden: Mental health is often affected when physical health gets in the way of a productive life.

Subplot: For some immigrants, new environmental factors and radical change in diets trigger symptoms.

As these vignettes demonstrate, patient testimonials can provide valuable insight for patient education and product positioning purposes. But more important, these interactions put a human face to the suffering and vulnerability that coexist with multicultural health issues. Respondents are typically grateful for the chance to speak out, and do so earnestly and passionately. The moderator must be prepared to strike a balance between the need to meet research objectives and the respondents’ eagerness to unload their burdens. Researchers can’t be dispassionate here - detachment may be interpreted as disrespect.

Clarifying objectives

As with any research project, clarifying objectives is essential. In multicultural health care research, it is imperative to understand where the client company sits on the multicultural learning curve in relation to the specific segment and category. Is a multicultural/multilingual strategy already in place? How much is already known about the target, and what assumptions currently inform marketing activities? How fresh is the information?

In the absence of baseline information, companies are advised to begin by conducting exploratory research with the aim of constructing a patient profile for the target around a specific therapeutic category. This profile may draw from a combination of qualitative and quantitative sources, along with insights collected in the cultural immersion phase (see below). The result is a comprehensive portrait of the patient that incorporates multiple, relevant and timely data sources. Exploratory research - from which the cultural backdrop for health awareness and behaviors emerges - has been found to better inform further research phases, including message development and testing of advertising and marketing materials.

Environment and context

Many of the multicultural projects conducted by our firm are preceded by cultural immersion visits in the markets where research is to take place. This process gives clients the opportunity to gain an understanding of the environment and context in which health care is sought and delivered.

Community clinics, hospitals, pharmacies, churches, youth centers and schools are among the sites to be visited on a given tour. Clients meet with health care workers, walk through neighborhoods, eat at local restaurants and are guests at health fairs or education sessions. Clients are taught to explore with all of their senses, taking field notes and photos where appropriate. We also invite the company’s local pharmaceutical rep, if applicable, to add perspective to the visit.

Appointments are made to speak informally with pharmacists, physicians and nurses, health educators and other health care workers. We work with the client to develop a list of targeted questions depending on the multicultural segment under study. These questions typically revolve around condition awareness; trust placed on various information sources; role of caregivers; understanding of risk factors; belief systems in place regarding disease states; and perceived compliance barriers.

Information gathered through these conversations is important in building the cultural backdrop during exploratory research phases. But just as important are more subtle cues identified during the tour.   When walking through clinic/hospital waiting areas, what types of literature, if any, are on display? In what language(s) are these available? Do waiting areas reflect the customs of the target population in terms of available space and amenities? Are family members and caregivers welcomed? Neighborhood drugstores - both chain and independent outlets - can offer clues about local consumer needs: Are screenings and vaccinations offered on-site? Are pharmacists multilingual? How prevalent are homeopathic facings in over-the-counter aisles? Do you see import products from various regions of the world?

Establishing criteria

The following factors are paramount in establishing recruiting criteria for multicultural pharma or health-related projects. (One side note: At the end of any discussion, respondents appreciate any literature they can take with them. This is a chance to place information in the hands of consumers who are thirsty for it.)

Hispanic market

The Hispanic or Latino market is the largest ethnic subgroup in the United States  . Any study aimed at understanding Hispanic health issues must take into account the diverse subgroups that compose the larger market. These include national origin, geography, language dominance, length of U.S. residency, acculturation levels, media consumption, educational attainment, income, age and gender.

National origin of Hispanics plays a role in helping to determine recruiting quotas for certain therapeutic categories. The Centers for Disease Control indicate that Puerto Ricans suffer disproportionately from asthma, HIV/AIDS and infant mortality, while Mexican-Americans suffer disproportionately from diabetes. These data, in combination with demographic statistics and geographic incidence, can guide the selection of research markets. Where national origin data for different conditions is not available, we recommend working in at least three geographically dispersed Hispanic markets to cover predominant nationalities.

Study objectives will determine, in part, the language in which Hispanic focus groups ought to be conducted. Exploratory research should incorporate a spectrum of language segments (Spanish-dominant, bilingual and English-dominant, for example). If message testing were the core objective, message language would determine the language of the groups. For text-heavy research, screening must determine literacy levels for written language.

African-American market

African-Americans share a disproportionate burden in a number of health conditions, including cardiovascular disease, some forms of cancer and diabetes. The Centers for Disease control indicate that factors contributing to poor health outcomes among African-Americans include discrimination, cultural barriers and lack of access to health care. Research among African-Americans can be conducted in traditional focus group facilities, but consideration should be given to meeting respondents in their communities as well, as family and faith are two important elements in African-American support systems.

Therapeutic segmentation/conditions

Understanding the incidence of certain conditions among ethnic and racial groups can help refine study samples, and secondarily, the markets where these groups are concentrated. The research team works with the client to identify key criteria, including time of diagnosis, treatment status, severity of condition, treatment satisfaction and co-morbidity.

During recruitment, care must be taken to carefully explain the purpose of the study and to emphasize that the study is not a clinical trial. The moderator must also underscore that she is not a physician or other health care worker.

Health insurance

Lack of access to health insurance by Hispanics and African-Americans is well documented. Any consumer study must include a cross section of health insurance status in order to obtain a representative view of experiences.

Higher risk

Multicultural populations are at a higher risk than their white counterparts to suffer from serious chronic and life-threatening illness. Market researchers can play a role in uncovering the cultural hot buttons that interfere with positive health outcomes, as well as approaches that can have a favorable impact on them. Health care and pharmaceutical organizations can benefit from gaining cultural competencies. The journey is gratifying, and our nation will be healthier for it.