and changed its behavior. Assessment of the effectiveness of the intervention in the target population generally requires controlling for confounding effects: for example, changes in the broader social environment in the direction of program intervention changes. These include public occurrences that infl uence people’s behavior in the direction of interven- tion (e.g., a prominent person’s AIDS-related death motivates people to adopt protective behaviors). Assessments of the effects of intervention also focus on political leaders and policymakers who have the potential to produce long-term changes. Long-term success is achieved by securing the necessary resources through infl uence on public leaders and bureaucrats. Leaders and organizations can produce long-term changes in the behaviors of communities through institutionalization of interventions into permanent programs.
“rapidly assessed” to ensure that they have had the intended consequences. The RARE process is interactive to adapt continually to new information and changing local conditions.
RARE is a cost-effective pragmatic approach that uses local resources to provide a multilevel analysis of community conditions, behaviors, and beliefs. It compiles multiple sources of archival data and combines them with up-to-date data to change behaviors with responses adapted to the specifi c needs of local vulnerable communities. It uses a wide range of methods, including existing information, formal surveys, informal inter- viewing, observations, focus groups, and cultural experts. Multiple overlapping data sources permit triangulation and enhance validity and reliability of fi ndings. Thus, con- sensus is more readily apparent. The different sources of data also provide more appeal- ing results and fi ndings for different audiences (e.g., what is convincing to physicians may be different from what convinces political representatives, community members, or patients). A principle of RARE is the representation of cultural variability—that is, differ- ent groups in the study area and differences within target subgroups. Individuals with special expertise in the area are recruited for interviews to establish both normative con- ditions and variation within the community.
RARE Sequences
RARE begins with an invitation from community leaders to address specifi c health prob- lems and uses community resources, facilitated by outside governmental consultants (e.g., U.S. Department of Health and Human Services entities such as the National Insti- tutes of Health [NIH] and the CDC). Consultants guide the development of group con- sensus about how to address the issues and train individuals and organizations in design, implementation, assessment, and analysis. Compilation of available data by consultants helps defi ne the problem to be addressed. Community involvement, responsibility, and ownership, which are fundamental aspects of RARE, facilitate the training and empower- ment of communities to respond to their health needs. The community concept funda- mental to the RARE process includes many stakeholders: political and health leaders, representatives of health organizations, members of targeted or vulnerable populations, and other community representatives and groups. The community provides the necessary information for the program, making decisions about the priorities for intervention and ensuring the cultural acceptability of the interventions. From the inception, the program is developed in collaboration with the community to ensure an accurate assessment of community needs, the community’s cooperation and responsiveness, and the relevance of the program to local needs. RARE methods focus on groups at high risk; those suffering from the condition; and the behaviors, beliefs, and values that increase risk and disease.
RARE Community Teams
The RARE approach utilizes forms of community collaboration and involvement. These are illustrated in Exhibits 4.2 and 4.3 and the following sections on the community advi- sory committee, the fi eld assessment team and methodological approaches, and the assessment modules.
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Community Advisory Committee The principal mechanism for community input is through a community advisory committee that represents elected offi cials, public (health) employees, and a wide range of constituencies and stakeholders. These may include offi cial and unoffi cial representatives of community groups, religious organizations, members of at-risk interest groups, and representatives of advocacy organizations. The inclusion of
EXHIBIT 4.2.
RARE Phases, Principles, and Advantages*Major Phases
Invitation from local political and health leaders
Creation of a community RARE working group and community forum for elicitation of concerns
A crises response team’s (CRT) rapid evaluation of existing data
The CRT’s proposal to local offi cials to identify major aspects of a problem and necessary research and interventions
Local fi eld research team selection and training by consultants Local fi eld research team, using
Contextual assessment
Risk and health consequences assessment Intervention assessment
Working group preparation of report and action intervention plan Principles
Invitation must come from local political and health leaders The primary investigator must have prior knowledge of the culture Community members must be involved in project development A single focus or problem area must be addressed
Local research teams with cultural competence in the community studied must be included
Programmatic interventions must be culturally based and relevant Programs must be assessed for their effectiveness
Advantages
Rapid response to pressing problems
Commitment of communities to assist in the research process Use of existing knowledge and resources
Multimethod approaches to increase validity and reliability Community-based orientation to create ownership
Enhancement of community power by training local research teams Quick development of culturally relevant and effective responses Assessment of intervention effectiveness
Use of multiple methods for triangulation and validity
*Adapted from Trotter and Needle (2000a, 2000b) and Stimson, Fitch, and Rhodes (1998).
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EXHIBIT 4.3.
RARE Assessment Modules*Initial Consultation Module
Identify information and gaps regarding scope of problem Ascertain existing community knowledge regarding condition Gain local perspectives on problem
Ascertain health and social consequences of condition
Assess existing treatments for condition and problems with them Identify vulnerable populations
Identify risk behaviors that need to be changed
Ascertain cultural and community contexts affecting interventions Research the different stakeholders and their priorities
Identify individuals, groups, and organizations to be included Establish, orient, and train community advisory committee (CAC) Provide database report to CEO, CAC
Convene CAC to determine priorities and action plan Use local knowledge to develop relevant interventions Create research team for assessment and intervention Ascertain resources available
Incorporate community in assessment, implementation, and evaluation Contextual Assessment Module
Study Area Profi le
Productive and reproductive infrastructure Domestic, economic, and political structures Policy, administrative, and ideological factors Locations of vulnerable populations
Locations conducive to high-risk behaviors Key Areas or Factors That Increase or Decrease
Spread of disease Health consequences Social consequences
Vulnerability and progress of disease among infected Access to treatments
Successful implementation of treatments Success of interventions
Behaviors associated with each key area or factor Contextual factors associated with key area or factors Key Contextual Assessment Foci
Factors Facilitating or Inhibiting Risks
Geographical features affecting risks and consequences Population movement relevant to spread of disease Economic and occupational factors affecting risks Particular social or ethnic groups with increased risk Effects of laws and criminal justice system on risk behaviors
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Factors Ameliorating or Exacerbating Health Consequences Attitudes and reactions of family, government, and society Provision of services by health care system
Factors impeding access and utilization Key health problems that affect focal disease
Role of social welfare system in addressing those with condition Factors Facilitating or Inhibiting Development of Interventions
Availability of health services
Educational services and media utilization Research and evaluation capacity Local groups affecting implementation
Ethnic and linguistic populations affecting implementation Governmental and health decision making
Alternative or complementary therapies Risk and Health Consequences Assessment
Extent and frequency of individual risk behaviors Individual motivation for risk behaviors
Levels of knowledge regarding risks Behavior- and context-specifi c risks Community norms affecting risk behaviors
Social Settings and Structural Factors Exacerbating Risks Means of reducing risks
Risks from individual lifestyle and living conditions Risks from values, beliefs, and norms
Barriers to risk reduction
Structural infl uences (e.g., policy, legal, governmental) on risk behavior Protective factors reducing risk
Social consequences of condition Effects of social responses on individual Social implications of diagnosis
Implication of condition for social relations Financial implications of condition Interventions Assessment
Existing interventions and effectiveness Need for expansion of existing interventions New interventions needed
Obstacles to effectiveness of interventions Factors ensuring sustainable interventions
Structural changes affecting access to interventions Environmental modifi cations enhancing access Education needed to infl uence service utilization Changes in community-based programs and policies Interventions modifying individual risk behaviors
*Adapted from Trotter and Needle (2000a, 2000b) and Stimson, Fitch, and Rhodes (1998).
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infl uential community leaders and trendsetters is important, as is the incorporation of critics of the system and traditionally excluded groups. The community advisory group provides a context for the community’s consideration of relevant data and ascertainment of the specifi c focus of the project. The community advisory committee must decide what research is most important to focus on, who is most vulnerable, and what can be done about it. The priority issue is then used to direct the activities of the fi eld assessment team, which is directly involved with the community advisory committee in carrying out the research and making the recommendations for interventions.
Field Assessment Team Community members and local cultural experts are central to the fi eld assessment team, which is locally recruited, incorporating health professionals and members of the community. These individuals have appropriate language skills, cultural knowledge, and community relations. The fi eld assessment team is knowledgeable about the health consequences of the disease being investigated. They are trained in the imple- mentation of RARE methods, including mapping, observations, key-informant interviews, focus groups, and surveys. They utilize the assessment modules for collecting and analyz- ing the data and as the basis for organizing the report and recommendations for the intervention.
RARE Assessment Modules
RARE uses four major modules for the evaluation of the local population, determination of the health problems to be addressed, and development of an intervention program (see Exhibit 4.3 and below):
Initial Consultation Module Contextual Assessment Module
Risk and Health Consequences Assessment Module Intervention Assessment Module
Initial Consultation Module The Initial Consultation Module provides overall direc- tion for fi eld assessments based on prior studies and evaluations. Results of local studies and national data sources are used to identify local conditions, risk profi les and vulnera- ble populations, the specifi c locale for study and intervention, the cultural context of risk for the focal disease, and the culturally appropriate interventions in risk behavior.
Key community representatives are recruited for the community advisory committee, which uses the data to decide the direction for the assessments, the local groups most in need of intervention, and the types of interventions needed. A community-based RARE fi eld team is developed to implement assessment, intervention, and evaluation processes.
Contextual Assessment Module The Contextual Assessment Module is designed to identify community information that locates the vulnerable populations in greatest need of services. It uses both existing sources of data and additional information acquired through
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direct observation, individual interviews, and focus groups. A principal aspect is a study area profi le focused on the economic, social, and political contexts of the problem. The Contextual Assessment Module is designed to identify the primary cultural, social, and situational factors that affect risk; the utilization of available programs for prevention and treatment; and the conditions needing to be addressed to implement a locally relevant intervention successfully. The community characteristics and dynamics that affect risks, the specifi c groups affected, and the nature of resources are assessed to ascertain appropri- ate interventions. Specifi c focus is placed on the factors that increase or decrease risk and contagion, the social and health consequences of disease, and the adoption of interven- tions. The structural factors and cultural conditions necessary for effectively implementing the intervention are identifi ed, including the macrolevel factors (physical, geographical, economic, administrative, organizational, political, religious) (see Exhibit 4.1 and Trotter and Needle, 2000b). Contextual assessment identifi es the key conditions to be modifi ed to reduce risk and enhance access to prevention and treatment programs. Contextual assess- ment data are used to develop an action plan of culturally appropriate interventions for the most vulnerable populations.
Risk and Health Consequences Assessment Module The Risk and Health Conse- quences Assessment Module identifi es the types, extent, and nature of risks and the behavioral processes and psychosocial dynamics associated with risk taking. The risk behavior’s broad implications for health, the behavior’s social consequences, and its extent in the populations are primary foci. Assessment identifi es the most vul- nerable populations based on risk behaviors and identifi es the factors that reduce risk. Risks are assessed at the level of individual behavior, communitywide norms and institutional processes, and the structural level of laws and policies affecting risk behavior.
Intervention Assessment Module Assessment of conditions affecting proposed interven- tions and their potential benefi ts builds on existing effective interventions. Interviews with the providers and vulnerable populations are key sources of data. The Intervention Assess- ment Module fi rst considers existing interventions and their adequacy and effectiveness from the perspective of the major stakeholders. Existing interventions are assessed as to their targeting strategies, appropriateness and accessibility, and the sociocultural and struc- tural factors inhibiting or facilitating their use. New interventions are developed based on gaps in coverage, lack of accessibility, and specifi c needs not currently met, particularly those of highly vulnerable populations. Proposed interventions consider environmental modifi cations; structural changes in programs and policies; and community changes in behaviors, attitudes, and knowledge to reduce risks. This information is summarized in a proposed action plan for incremental interventions based on existing programs and directed to changing behavior at individual, community, and structural levels. The approach is capa- ble of being accomplished within the scope of local resources and through multiple inte- grated strategies addressing the spectrum of levels that affect risk and severity. Changes in the delivery of services focus on enhancing availability, accessibility, and relevance. Where necessary, political and policy changes, such as funding new programs or mandating free
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access to services for low-income groups, may be sought to address health problems more effectively.
CHAPTER SUMMARY
The effective provision of care requires an understanding of the effects of culture on health behavior and clinical relations. Effective cross-cultural adaptation requires an ability to understand individuals within the context of their cultural systems. This chap- ter has provided models for understanding cultural systems and performing community assessments. The RARE approach provides advantages in creating community involve- ment in health issues and assessments at the level of relevant cultural beliefs and behav- iors. Beliefs provide the design for thought and behaviors, but ultimately it is what people actually do rather than merely think or believe that has the greatest implications for health. The next chapter addresses these health behaviors at the level of the family, com- munity ethnomedical traditions, and professional health practices.
Cultural Systems Effects on CVD
When we examine the multiple factors contributing to high levels of CVD in African Americans, it quickly becomes clear why a cultural systems model is necessary to consider all the factors affecting its manifestation. We can begin with the general ecological system, refl ecting the poverty-level lifestyle that characterizes a disproportionate number of African Americans. Eco- nomic factors expose them to a variety of risk factors for CVD: poor neighborhoods, with ram- pant criminal elements and drug use, compounded by limited public health care facilities.
These all constitute risk factors and contribute to increased stress, which exacerbates hyper- tension. Dangerous inner-city environments inhibit doing exercise (Bolton and Wilson, 2005), an important protective factor in CVD and stress reduction. Impoverishment affects dietary patterns, which are signifi cant contributory factors in hypertension. Traditional preferences for salty and fatty foods, particularly pork and fried chicken, aggravate hypertension and contrib- ute to CVD. The belief that their traditional foods are healthier than “white people food” can lead to neglect of medical advice regarding dietary changes (Schlomann and Schmitke, 2007).
Treatment utilization is affected by family, community, and religious self-care practices, as well as the insuffi cient public education and community care facilities. Addressing all of these inter- acting factors contributing to high CVD rates among African Americans must begin with understanding their health culture and its effects on symptom recognition, treatment seeking, and compliance with care directives.
BIOCULTURAL INTERACTIONS
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