Editor’s note: Michele Holleran is managing partner of Holleran Consulting, a York, Pa., research firm.
Minority health issues have come center stage in the past year as managed care has embraced new subscribers and uncompensated care by hospitals has reached an all-time high.
"Minority," for the purposes of this article, is defined as any group of persons under-represented in traditional population-based health research due to lack of access, interest, or ability to participate in such studies. Such individuals include the unemployed, homeless, illiterate, some ethnic minorities, the disabled, and medically indigent. As a group, these individuals represent a significant portion of the population. However, their individual health needs, risk behaviors and circumstances may look very different from one another. Certain types of health risk behaviors are more prevalent among this group and, therefore, health professionals stand to gain a lot by getting behind the health risk behaviors to understand motivations and perceptions which contribute to those behaviors.
A classic example is the case of Hispanic male youths who are encouraged by their Latin culture to smoke cigarettes. Because the number of Hispanics is growing in the United States, health professionals are very interested in understanding what, if anything, could be done to discourage smoking among this population. According to Healthy People 2000 (a national health initiative coordinated by the U.S. Public Health Service), tobacco use is estimated to cause more than one of every six deaths in the United States and is a major contributor to heart disease, lung and other types of cancers. Hispanic males residing in the United States are almost twice as likely to smoke (40 percent do) compared to the United States average.
As another example, it has been found that many African-American females with addictions and chronic health problems need non-traditional approaches to rehabilitation and disease management. Studies have linked these illnesses to "internalized racism" (the erroneous belief that African-Americans are inferior to some races), suggesting that until the self-esteem of these females is improved, their health will not.
Focus groups lend useful insight
Much of the knowledge we possess today about minority health has been garnered through qualitative research such as focus groups. Because many members of minority groups are skeptical of government or hospital sponsored survey processes, face-to-face research may be more appealing because it allows two-way dialogue. The perception of minority members is that their collective voice is heard more accurately and completely in a focus group session than it would be using a more impersonal technique such as a written or phone survey. Face-to-face research also allows participation by people who can’t read or write.
However, traditional focus group research has its limitations as well. Without anonymity, minority populations asked to discuss controversial health issues such as domestic violence, child abuse and sexual behaviors, may be hesitant to speak up unless their opinions can be shared confidentially. One tool useful in preserving confidentiality is a wireless keypad system. It works like this: participants are asked to respond to a statement such as, "Women who smoke during and after pregnancy put the lives of their children at risk." Participants are asked to indicate their level of agreement with the statement by pressing the keypad number that corresponds to their opinion (1 = strongly disagree; 2 = disagree; 3 = somewhat disagree; 4 = somewhat agree; 5 = agree; 6 = strongly agree). Once all the participants have voted, their numbers are recorded and displayed on a screen for all to see and discuss. This approach depersonalizes the opinions and can reassure participants who see that others may share their same opinions. Often this realization prompts participants to talk about why they hold a certain opinion. A skilled facilitator can further probe group members by asking questions about their knowledge on certain health subjects and their personal risk behaviors. Going further, the facilitator can often learn about what would need to change in order for the risk behavior to be eliminated. In the case of smoking during pregnancy, women’s perceptions can change after they hear concrete evidence that smoking contributes to low birth weight babies, as well as asthma and respiratory illness among young children.
In one memorable focus group session, the facilitator was able to uncover why poor women living in Appalachia refused to have breast screenings even when those screenings were free and offered at convenient locations.
Shared one participant: "Now what am I supposed to do if I found out I did have breast cancer? I’d have to get an operation, get chemotherapy, have a long recovery and end up dead within a year anyway. I’d be worried sick the whole time and drive myself crazy, not to mention fret about the cost of medical bills. How would this affect my kids, knowing their mama is going to die? No ma’am I don’t need to or want to know if I have breast cancer. I’d be better off just not knowing and letting nature take her course."
Getting behind the whats and delving into the whys of behavior helps health professionals gain insight on how to remove barriers and develop non-traditional solutions for minority populations.
Education and the right communications message
Sometimes those solutions lie in more accurate education or a message from a compelling, respected spokesperson with whom they identify. This was the case in a northern New Jersey town where prostate cancer among male African-Americans was significantly higher than rates among other ethnic populations. A national awareness campaign featuring actor Danny Glover encouraged African-American men to have prostate cancer screenings. The message was delivered through African-American churches and the local hospital offered the screenings free at convenient locations. This campaign was enormously successful and resulted in a sizable number of prostate cancer screenings among the target population.
Profiling high-risk minority populations has interesting implications for disease and demand management programs. Persons in minority groups are often categorized as "avoiders," meaning they avoid care unless they are severely ill or injured; they are not particularly interested in seeking health information and they are minimally involved in their own health or the health of their families. Consequently, they are less responsive to communications about their health and much less likely to be motivated about disease prevention and management. However, they will respond if approached in a manner that is culturally sensitive and hits a hot button.
Cluster sampling as an alternative
Cluster sampling is another useful technique used to identify health needs among minority populations. The homeless are more likely to participate in a health survey process if they are able to be led through a facilitated session at a convenient, safe location within their community. Such research can shed light on the propensity of the homeless to have their children immunized, eat a healthy, balanced diet or be at risk of AIDS. Such information can help public officials establish policies and health care marketers devise appropriate communication messages.
Data from cluster sampling should be viewed as directional input because it is not considered projectable to the entire sub-population universe being studied. A cluster sample is a more informal process, gathering together groups of people who fit a certain demographic or psychographic profile to participate in a survey process. Nonetheless, if enough individuals are recruited for participation, strong trendlines emerge, giving health researchers excellent insight into areas of concern. As with focus groups, cluster sample participants may need to be given a monetary incentive in exchange for their feedback.
Self-management is the long-term strategy
Self-management of health is a crucial dimension of demand management, the concept of the right amount of care at the right time. Health professionals today strongly advocate the adage "an ounce of prevention is worth a pound of cure," especially in this era of managed care.
Given that preventive health self-management is more readily embraced by better educated, higher income groups with few access barriers, this poses a challenge for health marketers. How can health providers provide incentives to certain minority populations (the "avoiders") to better manage their personal health so they won’t end up in the emergency room with a costly illness or disease? The answers are complex and vary greatly by each sub-population. Each group has different reasons for neglecting their health. Focus group and cluster sample research can get to the bottom of them.