Preventive Care - Key Activity 20

KEY ACTIVITY #20:

Develop Customized Culturally Appropriate Educational Materials

 

This activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; proactive patient; care coordination; address social needs.

Overview

This activity provides guidance on how practices can curate and use existing educational materials and/or develop and use culturally appropriate educational materials to increase the rate of patients who complete recommended colorectal cancer, breast cancer and cervical cancer screening.

Numerous studies[1][2][3][4][5][6][7] have demonstrated that patient education – both self-directed and guided by a member of the care team – is an effective and efficient strategy for getting patients screened for colorectal, breast and/or cervical cancer. Patient education about their risk of cancer, the recommended screening tests, the risks and benefits of the testing methods, and how the tests are performed helps to support informed decision-making, and education is more likely to be followed if it is delivered in ways that are meaningful to the patient, culturally relevant and linguistically appropriate.

Many EHR platforms allow for the development or customization of embedded patient education material. Those tools can then be available for all care team members to share with patients in one of several modalities: at the health center, by mail, or via patient outreach and engagement technologies. Patient outreach and engagement technologies can assist the care team in assessing screening hesitancy, as well as deliver education. These technologies can be programmed to deliver scripted responsive interactions that can extend the ability of the care team to spend time addressing concerns and questions. Care dashboards and quality reports can be utilized with data analytics to identify trends that might suggest population level strategies. Clinical templates and/or prompts in the EHR and care coordination applications can guide provider and care team discussions.

Action steps and roles

1. Use data to determine the populations of focus for new educational materials.

Suggested team member(s) responsible: Panel manager or data analyst and multidisciplinary team for cancer screening.

All patients can benefit from educational materials, and we cover the tailoring and use of existing educational materials in Key Activity 10. Use Culturally Appropriate Educational Materials for Cancer Screening.

This step, however, is focused on determining which populations will require new customized culturally relevant materials to increase their rates of recommended cancer screenings. To determine who might require more new materials, determine which populations or sub-populations within your practice have the lowest rates of screening.

These populations vary by practice but often include:

  • Patients of color.
  • Patients for whom English in not their primary language.
  • Immigrants and refugees.
  • Patients with no insurance or high-deductible insurance plans.
  • Patients with behavioral health needs.
  • Patients experiencing homelessness or housing instability.
  • Patients with physical or developmental disabilities.
  • Other people who are underserved or medically disadvantaged.

It might also be useful to develop more customized strategies for three populations:

  • Patients who are regularly seen by the practice for other health-related reasons (active patients).
  • Patients who have been seen by the practice in the past but not over the last 12 months (inactive patients).
  • People who are on the practice’s panel but have not been seen by the practice (empaneled, but not yet seen patients).

 

2. Gather insights on each population of focus identified by the gap reports.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening.

Using one or more human-centered design methods, such as focus groups, 7- Stories, Journeymapping, etc. (see resources on human-centered design below), and work with patients of the population of focus to better understand:

  • Their assets, needs and preferences.
  • Cultural beliefs, including traditional healing practices.
  • Beliefs and level of trust in healthcare generally and in cancer screenings specifically.
  • Barriers to getting screened for this population.
  • Trusted sources of information or communication mechanisms for this population.
  • How they like to receive information (e.g., written, video, as a part of a conversation, etc.).
  • Their ideas for increasing cancer screening rates.

 

3. For each population of focus, use the insights to develop new ideas.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening.

Based upon the insights your practice has developed for a population of focus, use one or more human-centered design methods (see resources on human-centered design below), to develop ideas for new educational materials for them. Creating these ideas is best done with representatives of the population of focus, as they have expertise and experience that may be missing from the practice’s care team.

Before developing the ideas, it is useful to remind the team involved of the common elements and approaches involved in tailoring educational content and messaging for any population of focus. This includes:

Language and tone:

  • Developing materials in language(s) spoken by the population of focus.
  • Using simple language free from medical jargon. Ensure readability and comprehension of material for all education levels.
  • Ensuring that the tone is empathic, respectful and culturally sensitive.
  • Using familiar concepts for the population of focus, including incorporating familiar symbols, metaphors and analogies that resonate with their culture(s).

Use of visuals: Use images, familiar symbols, graphics, illustrations, video and/or other visual media that are culturally relevant to population of focus.

Incorporate storytelling:

  • Use personal stories from patients of the population of focus who have undergone screenings to emphasize the benefits.
  • Share success stories of community members who have undergone screenings to encourage others.

Identify the most appropriate messengers and mechanisms: This includes asking and answering the following questions:

  • Who are the best people or groups to get the message across? Should we partner with others for this?
  • What communication mechanisms are most appropriate for the population of focus?
  • Are there culturally significant events or holidays to convey the message of prevention and care?
  • Where should we distribute these materials (e.g., practice waiting areas, community events, local organizations trusted by the population of focus, etc.)?

Accuracy and alignment with clinical guidelines: This involves having new materials reviewed by experts to ensure they adhere to clinical guidelines.

 

4. Organize the ideas for testing that your practice has come up with.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening.

Now that you have a lot of ideas, it may be helpful to organize them by theme or other criteria. This might include organizing the ideas for new materials in the following categories:

  • Materials related to education on the importance of cancer screening.
  • Materials related to education on the testing modalities available.
  • Materials related to education on the benefits and potential risks of screening.
  • Materials related to education on common misperceptions related to cancer screening.
  • Materials related to addressing specific barriers to screening, including coverage and potential out-of-pocket expenses.
  • Miscellaneous materials or ideas that don’t fit into the above categories.

 

5. Prioritize ideas for testing.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening.

The steps above have likely generated dozens of ideas for new materials. Your practice likely doesn’t have the bandwidth to test all of them, at least not at the same time,so now is the time to prioritize a few to begin testing. There are many ways to prioritize ideas. The Institute for Healthcare Improvement often recommends a .

If you have organized your ideas for new materials into themes or categories (see step above), you may choose to work on one category or select one or two ideas per category to work on.

The number of ideas that you prioritize for testing first should be based on the team’s bandwidth to engage in testing. So, it is critical to determine the bandwidth for the team(s) who will be doing the testing so that you can determine how many ideas to test first.

 

6. Begin testing your prioritized ideas for the population of focus.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening.

Whenever testing new educational material or communication mechanisms, we recommend that the practice:

  • Start with smaller scale tests (e.g., test with one patient, for one afternoon, in a mailing to 10 patients, etc.).
  • Study the successes and challenges of the test. When feasible, this should include getting feedback from patients directly after testing new materials or a new approach with them and incorporating their feedback into your next test.
  • Refining the process or material, as needed, based on the test
  • Testing again, increasing the scale of the test as these tests result in fewer challenges and better results.

 

7. Once you have tested, refined and scaled up the initially prioritized ideas, begin testing other ideas.

Suggested team member(s) responsible: Multidisciplinary team for cancer screening.

This might include going back to the ideas developed previously but not prioritized and/or going back through steps three to six above to develop and prioritize new ideas and potentially for additional populations of focus.

 

8. Put in place formal and informal feedback loops with patients and the care team.

Suggested team member(s) responsible: QI lead or their designee.

To help ensure that new educational materials are meeting the needs of patients and the processes involved are consistently feasible for the care team, it is important to have both formal and informal feedback loops.

For patients, feedback loops might include:

  • Sharing draft materials with the population of focus to gather feedback and ensure accuracy before testing.
  • Getting feedback from patients directly after testing new materials or a new approach with them and incorporating their feedback into your next test.
  • Patient satisfaction surveys (or similar).
  • Follow-up calls with a subset of patients to understand what works well and what could be improved.
  • Patient focus groups.
  • Having the practice’s patient advisory board (or similar) provide feedback.

For the care team, feedback loops might include:

  • Existing or new staff satisfaction and feedback mechanisms.
  • Regularly scheduled meetings or calls to get staff feedback on processes, methods and tools.

Implementation tips

  • If your practice has successfully developed tailored messaging and communication mechanisms for a population of focus on cancer screening or other clinical topics in the past, consider using this as you develop additional tailored materials and mechanisms related to cancer screening.
  • Conduct focus groups or other methods to gather information from patients and learn about their cultural beliefs and methods that they prefer.
  • When materials are being translated, ask others who have fluency in the language to read the materials and confirm their understanding.
  • Borrow from other health centers but be sure to test aspects in your own community. Language, materials, and techniques may resonate better in one community than another.
  • See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

Endnotes

  1. Cooper CP, Gelb CA. Opportunities to Expand Colorectal Cancer Screening Participation. J Womens Health (Larchmt). 2016 Oct;25(10):990-995. doi: 10.1089/jwh.2016.6049. PMID: 27749190; PMCID: PMC6066278.  
  2. Gwede CK, Sutton SK, Chavarria EA, Gutierrez L, Abdulla R, Christy SM, Lopez D, Sanchez J, Meade CD. A culturally and linguistically salient pilot intervention to promote colorectal cancer screening among Latinos receiving care in a Federally Qualified Health Center. Health Educ Res. 2019 Jun 1;34(3):310-320. 
  3. Dalton AF, Golin CE, Morris C, et al. Effect of a Patient Decision Aid on Preferences for Colorectal Cancer Screening Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2022;5(12):e2244982. doi:10.1001/jamanetworkopen.2022.44982. 
  4. Reuland DS, Brenner AT, Hoffman R, McWilliams A, Rhyne RL, Getrich C, et al. Effect of Combined Patient Decision Aid and Patient Navigation vs Usual Care for Colorectal Cancer Screening in a Vulnerable Patient Population. JAMA Internal Medicine. 2017 Jul 1;177(7):967. 
  5. Coronado GD, Golovaty I, Longton G, Levy L, Jimenez R. Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics. Cancer. 2010 Nov 8;117(8):1745–54. 
  6. Tong EK, Nguyen TT, Lo P, Stewart SL, Gildengorin GL, Tsoh JY, et al. Lay health educators increase colorectal cancer screening among Hmong Americans: A cluster randomized controlled trial. Cancer. 2016 Aug 26;123(1):98–106. 
  7. Nguyen TT, Tsoh JY, Woo K, Stewart SL, Le GM, Burke A, et al. Colorectal Cancer Screening and Chinese Americans: Efficacy of Lay Health Worker Outreach and Print Materials. American Journal of Preventive Medicine. 2017 Mar;52(3):e67–76.