3.2.1. Intervention Type

The strategies/interventions to address racial/ethnic health and healthcare disparities did not fall into clean categories. We used study author intervention labels when provided, but often had to categorize the interventions by study descriptions or statement of the primary purpose or approach. Through this process, we grouped the interventions into 12 types, or categories. All categories except the “Other Single Component” category represented interventions that were comprised of bundles of intervention components. These categories could not be designed to be mutually exclusive, and while each study was placed into only one category, the detailed descriptions of the interventions generally involved considerable overlap in the components used. Thus, for example, patient education may have been examined as a study author-identified intervention, yet patient education can also be a reasonable and common element in many intervention categories.

Multiple definitions exist in the published literature for intervention types in health services research. Below, we provide definitions that can be considered conventional and fairly describe our categorization scheme, organized from most to least commonly reported in the literature.

Self-management support can be broadly defined as an intervention designed to help patients better manage health conditions through education, training, and support to improve knowledge, skills, or psychological and social resources, together with self-monitoring and regular review from health professionals.^{197, 198} The interventions may incorporate patient education, appointment reminders, and adherence to medication and care plans. One example was a community health worker involved, self-management support study to help African Americans with hypertension overcome barriers to self-management for through enhancement of shared decision-making skills and problem-solving skills.³⁸

Prevention/lifestyle support refers to interventions that aim to prevent or delay the onset of disease or disease symptoms through risk reduction. It commonly introduces activities that limit risk exposure or decrease the susceptibility of at-risk individuals to prevent disease from progressing. It emphasizes early disease detection and targets healthy-appearing individuals.¹⁹⁹ The interventions may include elements such as exercise coaching, diet coaching, or referral for treatment. For example, one study described a lifestyle intervention delivered by a trained, same-race community health worker who supported African American women with type 2 diabetes in making small changes in diet and activity level.¹¹⁵

Patient navigation refers to services that improve engagement in healthcare by providing personal guidance through the healthcare system.²⁰⁰ Patient navigators often help patients overcome challenges to following their healthcare plan, allowing them to progress efficiently through treatment.²⁰¹ For example, one study assessed the impact of a patient navigator program on adherence to followup appointments and psychosocial outcomes among Vietnamese-American women who received abnormal mammogram findings. The patient navigator provided emotional support, education, translation, and assistance with understanding medical bills and doctor’s appointments.¹⁷³

Care coordination can be defined as organizing patient care activities between two or more participants to improve delivery of healthcare services. Organizing care involves the marshalling of personnel and other resources needed to carry out required care activities and managing the exchange of information among participants responsible for different aspects of care.²⁰² Examples of broad care coordination approaches include: teamwork, care management, medication management, health information technology, and patient-centered medical home.²⁰³ For example, one study enrolled an uninsured population of multiple race/ethnicities, and examined care coordination involving population health services and the Patient-Centered Medical Home (PCMH). Participants received primary care visits at the PCMH and attended at least one Population Health wellness, prevention, or social determinants of health (SDOH) program to improve outcomes for type 2 diabetes and cardiovascular disease, as well as to reduce hospital utilization.¹⁰⁶

System level quality improvement (QI) involves the use of a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement within a healthcare setting.²⁰⁴ One example was a QI project to improve equitable access to cervical cancer screening and management for Hispanics.¹⁰⁵ Following a preparatory stage that included a systematic review of cervical cancer screening, the project included 1) team engagement through team meetings; 2) patient engagement via a tool on cervical cancer screening provided in both English and Spanish (an adaptation of the Ottawa Personal Decision Guide); 3) a Well Woman Health Check Program (WWHP) eligibility screening and enrollment tool for registration staff that included updated registration guidelines and a WWHP registration log of all women enrolled in the program; and 4) the implementation of a case log for case management.

Patient education provides learning experiences on health topics, and can be defined as the process of influencing patient behavior and producing the changes in knowledge, attitudes, and skills to maintain or improve health.²⁰⁵ For example, one intervention led by community health workers examined whether group education is as effective as individual culturally tailored education in improving cervical cancer screening among underserved Hispanic women.⁴³ Another intervention examined whether computer-tailored patient education improved colorectal cancer screening among low-income African Americans.¹⁴³

Collaborative care model is a systematized way of managing care and treatment for people with chronic conditions. It is a multiprofessional approach to patient care that adopts four key components: (1) a multiprofessional approach to patient care; (2) a structured management plan tailored to the individual needs of the patient; (3) proactive followup delivering evidence-based treatments; (4) processes to enhance interprofessional communication such as routine and regular team meetings and/or shared record.²⁰⁶ One study that illustrates the collaborative care approach used a pharmacist-physician model to reduce the time to goal blood pressure in an uninsured population comprising mostly (80%) Black adults.¹³¹

Comprehensive system level change refers to a redesign of a healthcare system model and may include a collaboration between healthcare organizations and community-based organizations or public health systems. One example is a study that incorporated a centralized community clinic linkage hub to connect patients to community resources for participating clinics.⁵⁹

Mobile Health (m-Health) single component refers to using mobile and wireless devices to improve health and deliver care through text messaging, wireless data transmission, and smartphone apps to send health-related information.²⁰⁷ In one m-Health intervention, Hispanic people with type 2 diabetes received up to three motivational, educational, and/or call-to-action texts per day over 6 months.⁸⁶

Coordination of transitions of care can be defined as movement of patients between healthcare practitioners and settings as their condition and care needs change. Transitions may occur between hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities.²⁰⁸ One illustrative study enrolled high-need, high-cost patients who were predominantly non-Hispanic Black, and examined hospital-based, real-time screening, patient engagement, enrollment, enhanced discharge care coordination, intensive home visits, and telephone follow-up for at least 45 days.³¹

Electronic health record (EHR)-based interventions comprise real-time, patient-specific data platforms that make secure information available immediately to authorized users. EHRs are designed so that information can be shared with other clinicians or healthcare providers and organizations, such as laboratories, imaging facilities, consultants, pharmacies, and collaborating inpatient and outpatient clinics.²⁰⁹ One EHR study examined a laboratory health information exchange (LHIE) system intervention that involved a bi-directional exchange of laboratory information (between ordering physician and laboratory staff) through an existing EHR system to improve antiretroviral therapy (ART) use.⁶⁰

Other single component category captured interventions examining a single component but were not otherwise easily grouped. These single components could potentially be added to other complex interventions and may in fact be present in any of the other intervention categories listed above. These single component interventions included language concordance,¹⁵⁸ a screening decision aid,⁹⁶ risk calculator counseling,¹⁴⁹ training in Web portal use,¹¹⁶ automated appointment reminders,¹²⁶ shared medical appointments,¹³³ group education for community-to-clinic settings,¹⁹³ attending one population health program per year, and stress management training tools,¹¹³ to mention a few.

Figure 3 displays the breakdown of intervention types across the included studies. The largest category (22% [35/163]) of included interventions was self-management support.^{27, 34, 37, 38, 41, 42, 50, 65, 66, 76, 77, 80, 91–93, 95, 110, 112, 117, 120, 124, 128, 132, 135, 136, 139, 141, 142, 159, 165, 170, 171, 175, 178, 189} Other interventions that accounted for a relatively larger proportion of our included studies were patient navigation (12% [20/163]),^{29, 48, 57, 58, 61, 69, 75, 81, 97, 119, 122, 127, 130, 145, 150, 162, 167, 173, 174, 180} followed by prevention/lifestyle support (12% [19/163]),^{23, 30, 36, 40, 49, 67, 68, 87, 111, 115, 125, 152, 154, 156, 168, 172, 184, 185, 194} then care coordination (9% [14/163]),^{28, 32, 44, 47, 52, 71, 101, 102, 104, 106, 137, 151, 161, 195} and system level QI interventions (8% [13/163]).^{33, 39, 56, 63, 64, 85, 99, 105, 121, 153, 166, 187, 191} Overall, patient education,^{24, 43, 53, 55, 74, 83, 107, 143, 146, 176, 188, 190} collaborative care models,^{72, 73, 84, 100, 129, 131, 144, 148, 164, 169} comprehensive system level change,^{54, 59, 88, 114, 155, 163, 177} single component m-Health,^{26, 51, 70, 86, 192, 196} transition of care,^{31, 82, 118} and EHR-based interventions^{35, 60} accounted for 24 percent of included interventions. Transition of care and EHR-based interventions accounted for the smallest category of included interventions (2% [3/163]) and (1% [2/163]), respectively). Other single components category (captured interventions examining a single component but not otherwise easily grouped) accounted for 14 percent (22/163) of the included interventions.^{25, 45, 46, 78, 79, 90, 96, 108, 109, 113, 116, 123, 126, 133, 138, 147, 149, 157, 158, 160, 179, 193}

Figure 3

Number of studies by intervention type. Note: We used wherever possible the exact terms used by study authors to label the interventions. Other single component interventions category captured interventions examining a single component but not otherwise (more...)

3.2.2. Intervention Target

We describe our categorization scheme for the intervention target in the Methods section. Interventions were targeted at various parts of the healthcare system—i.e., we identified patient targeted, clinician targeted, and healthcare system targeted interventions. Single targeted interventions (also referred to as single level interventions in this report) are those that target only one part of the healthcare system, such as only the patient. Multitargeted interventions (referred to as multilevel interventions in this report) are those with components that target more than one part of the healthcare system. One example of a multilevel intervention targeted at the healthcare system and the patient would be an intervention that incorporated a centralized community clinic linkage hub to connect patients to community resources for participating clinics.⁵⁹

Figure 4 displays the breakdown of intervention targets across the included studies. Self-management support interventions mainly targeted patients as a single level intervention (16% [26/163]),^{37, 38, 42, 50, 65, 66, 76, 77, 91, 92, 95, 112, 117, 124, 128, 132, 135, 136, 139, 141, 142, 159, 171, 175, 178, 189} followed by prevention/lifestyle support (10% [17/163]),^{23, 36, 40, 67, 68, 87, 111, 115, 125, 152, 154, 156, 168, 172, 184, 185, 194} and patient navigation (10% [17/163]).^{29, 48, 57, 58, 61, 69, 75, 81, 97, 119, 130, 145, 150, 162, 167, 173, 174} No study reported on single level interventions targeted solely at clinicians. All clinician targeted interventions were part of multilevel interventions, most often occurring alongside patient targeted components or healthcare system plus patient targeted components.

Healthcare system targeted interventions accounted for very few (4% [6/163]) included studies of single targeted/level interventions (i.e., target the healthcare organization), most of which were collaborative care model interventions.^{73, 129, 131, 144} Most healthcare system targeted intervention (31% [51/163]) studies were part of multilevel interventions, and most of these included patient targeted components or clinician plus patient targeted components.

Thirty-eight percent (38% [62/163]) of included studies examined multilevel interventions.^{24, 25, 27, 30–35, 39, 41, 45, 49, 51, 54, 56, 59, 60, 63, 64, 72, 78, 80, 84, 85, 88, 90, 93, 99–102, 104–107, 110, 113, 114, 120–122, 127, 133, 143, 148, 153, 155, 158, 161, 163–166, 169, 170, 177, 180, 187, 191, 195} Most of the multilevel interventions (22% [36/163]) of included studies) were healthcare system plus patient targeted interventions.^{27, 31, 34, 39, 54, 59, 60, 63, 64, 72, 84, 85, 88, 90, 93, 99–101, 104, 106, 110, 113, 127, 143, 153, 155, 161, 163–166, 169, 180, 191, 195, 196} Most of the healthcare system plus patient targeted interventions were system level QI interventions (5%, [8/163] of included studies).^{39, 63, 64, 85, 99, 153, 166, 191} One exemplar study reported the adaptation and implementation of Kaiser Permanente’s Hypertension management program targeted at multiple race/ethnicities (but enrolling predominantly Hispanic people) and rolled out healthcare system wide in 12 urban safety net clinics.⁸⁵ The intervention consisted of four key elements: (1) development of internal hypertension patient registry; (2) evidence-based treatment intensification protocol; (3) standardized blood pressure measurement protocol; and (4) blood pressure check visits.

Other multilevel interventions were (1) patient plus clinician targeted interventions (7% [11/163] of included studies) that were mostly self-management support interventions,^{41, 80, 120, 170} followed by patient education interventions;^{24, 107} (2) healthcare system, clinician, plus patient targeted interventions (7% [11/163] of included studies) that were mostly system level QI interventions;^{33, 56, 105, 121} (3) healthcare system plus clinician level interventions (2% [4/163] of included studies) that were system level QI interventions, an EHR-based intervention, and “other single component” intervention. Healthcare system plus clinician level interventions accounted for the lowest number of studies.

Figure 4

Intervention type by target. Note: Patient targeted interventions refer to interventions that related directly to patient behavior. Clinician targeted interventions refer to interventions that are related directly to clinician behavior. Healthcare system (more...)

3.2.3. Study Design

We classified included studies according to the authors’ reported study designs, illustrated in Figure 5. Some categories for study designs might overlap (e.g., quality improvement study design could overlap with cohort observational study design). A notably large number (58% [94/163]) of included studies were randomized controlled trials (RCTs). Among RCTs, the most frequently examined intervention was self-management support, followed by some “other single component,” then patient navigation and prevention/lifestyle support interventions. Other reported study designs include pre-post, mixed-methods, observational cohort study with comparator arms, nonrandomized controlled trial, quality improvement, or implementation science (to improve understanding of how to implement interventions). System level QI and collaborative care model interventions mostly did not use RCT study design.

Figure 5

Intervention type by study design. Note: We classified the included studies according to the authors’ reported study design. We used wherever possible the exact terms used by study authors to label the interventions.

3.2.4. Outcomes

We present mainly the authors’ reported primary outcomes to show the key focus of the studies. Some studies reported secondary outcomes. Evidence tables of data from all included studies in Appendix D present reported primary (including direction of effect), and secondary outcomes. Table 1 provides information on the outcome categories used.

Table 1

Outcome categories.

Figure 6 provides the breakdown of outcomes by intervention type. Studies commonly reported process and clinical outcomes as primary outcomes. Forty-one percent (68/163) reported process of care outcomes and 31 percent (51/163) reported clinical outcomes as primary outcomes. More specifically, prevention/lifestyle support and m-Health single component interventions mostly reported clinical and process of care outcomes. Self-management support, “other single component,” patient navigation, and patient education interventions mostly reported process of care outcomes. Collaborative care model and care coordination interventions mostly reported clinical outcomes.

Very few studies reported information on equity of service^{35, 52, 63, 81, 121} as primary outcomes. Only 3 percent (5/163) of studies specifically assessed reduction of disparities by reporting primary outcomes that directly measured equity of service between racially/ethnically minoritized people and other groups. Patient navigation,⁸¹ system level QI,^{63, 121} care coordination,⁵² and EHR-based³⁵ intervention studies reported equity of service outcomes.

Care utilization and patient experience of care were also limited in the literature. Care utilization was reported in 3 percent (5/163) of studies as a primary outcome. “Other single component” (such as automated appointment reminder and interactive kiosk-delivered education),¹⁷⁹ patient education,^{43, 83} and transition of care¹¹⁸ interventions reported care utilization outcomes. Two percent (3/163) of studies reported patient experience of care^{37, 40, 158} as a primary outcome. Only self-management support,³⁷ “other single component” (language concordant care),¹⁵⁸ and prevention/lifestyle support⁴⁰ interventions reported patient experience of care outcomes.

Multiple category outcomes were reported in 19 percent (31/163) of studies as primary outcomes. Most system level QI interventions reported multiple outcomes.^{39, 105, 166, 187, 191} Cost/financial reimbursement outcomes were lacking as either primary or secondary outcomes. Cost/financial reimbursement outcomes were reported alongside other types of outcomes and categorized as “multiple outcomes” in two studies that examined a collaborative care model intervention,^{129, 164} and a comprehensive system level change intervention.⁸⁸ These three studies were in fact the only studies in our literature set that reported cost/financial reimbursement outcomes.

Figure 6

Intervention type by outcome categories. Note: We classified the included studies according to the authors’ reported outcomes. We used wherever possible the exact terms used by study authors to label the interventions.

3.2.5. Intersectional Factors

We aimed to document other intersectional influences in addition to race/ethnicity (e.g., income, sexual orientation, geographic location, language, gender)²¹⁰ that had been a focus in the included studies; however, studies did not report this.

3.2.6. Cultural Adaptation and Community Involvement

Cultural adaptation is when interventions are modified to consider language, culture, and context. When adapted, the essential components of interventions are maintained but delivered in ways that are compatible with the participant’s cultural patterns, meanings, and values in order to increase relevance and engagement.²¹¹ Forty-four percent (71/163) of studies reported some form of cultural adaptation, such as availability of an interpreter, information offered in several languages, use of culturally aware peers, and use of community health workers that share sociodemographic characteristics with the patient population served (including race/ethnic background and language).^{24, 27, 39, 40, 43–46, 48, 49, 51–53, 55, 63, 66, 69, 71, 74, 75, 80–84, 86–88, 92, 93, 96, 99, 100, 105, 106, 111, 113, 114, 117, 119, 120, 125, 128, 132, 133, 135, 138, 139, 143, 145–147, 152, 158, 159, 164, 168, 171, 173–176, 179, 180, 184, 185, 188, 193–196}

Notably, a high number of patient education interventions (83% [10/12]) reported some form of cultural adaptation. Cultural adaptation was used in other intervention categories as follows: self-management support (40% [14/35]); prevention/lifestyle support (53% [10/19]); patient navigation (45% [9/20]); care coordination (36% [5/14]); system level QI (31% [4/13]); collaborative care model (30% [3/10]); comprehensive system level change (28% [2/7]); m-Health (50% [3/6); and transition of care (33% [1/3]).

In addition, a minority of studies (34% [24/70]) that enrolled participants from more than one racially/ethnically minoritized group or enrolled racially/ethnically minoritized people along with white participants reported some form of cultural adaptation.^{39, 40, 44–46, 53, 55, 63, 66, 69, 82, 83, 92, 93, 125, 132, 139, 145, 147, 152, 159, 164, 171, 174}

Community involvement (either partnership or collaboration) is defined as a process of healthcare systems working collaboratively with community organizations or groups of people to address issues affecting their health and well-being.²¹² These affiliations may be based on geographic proximity, special interests (such as religious institutions, faith-based wellness centers, faith-based social service agency, and community health centers), or similar situations (such as peers with similar health conditions). Thirty-nine percent (63/163) of studies reported community involvement (either partnership or collaboration).^{23, 25, 28, 35, 43, 48, 50, 52, 57, 59, 61, 69, 74, 81, 84, 87, 101, 102, 106, 109, 111, 115, 117, 119, 122, 125, 127, 129, 130, 132, 133, 139, 141, 143, 145, 148, 152, 156, 158, 159, 161, 162, 164–166, 168, 169, 171–176, 178–180, 184, 185, 188, 193–196}

Notably, a high number of patient navigation interventions (70% [14/20]) reported some form of community involvement such as religious institutions and community health centers. Other interventions that reported community involvement include: prevention/lifestyle support (63% [12/19]); self-management support (29% [10/35]) care coordination (50% [7/14]); patient education (42% [5/12]); collaborative care model (50% [5/10]); system level QI (8% [1/13]); comprehensive system level change (14% [1/7]); m-Health (17% [1/6]); and EHR-based interventions (50% [1/2]). Transition of care interventions did not report any form of community involvement.

3.2.7. Harms or Adverse Events

A chronic pain self-management educational program identified falls as an adverse event that occurred during usual activities outside the self-management support program; however, authors noted that patients might have been more active than usual due to the influence of the program.¹⁷⁸ No other study reported harms or adverse events of interventions (such as unintended negative consequences, including misallocation of effort, decreased patient satisfaction, stigma, etc.) Similarly, we found no additional information on harms or adverse events of interventions in the gray literature.

3.2.8. Applicability and Sustainability of Interventions

In this Brief, applicability is defined as the extent to which the intervention could be implemented in a setting other than the one where it was researched.²¹³ Overall, studies did not report on the feasibility or ease of adhering to the intervention in other environments. However, two studies (with no reported findings on applicability) highlighted that their interventions were potentially applicable/generalizable to general clinic settings because they tested them under real-world conditions following previous success in a randomized controlled trial.^{110, 195} One study focused on a Mobile Insulin Titration Intervention (MITI) program, which was a multilevel, patient plus healthcare system targeted intervention to help patients with type 2 diabetes find their correct basal insulin dose without in-person care.¹¹⁰ The other study examined a Prevention of Cardiovascular Outcomes in African Americans with Diabetes (CHANGE) intervention, which was a multilevel, patient plus healthcare system targeted intervention aimed at improving adherence to medication for cardiovascular disease.¹⁹⁵

Sustainability was defined in this Brief as the continued use of program components and activities for the ongoing achievement of desirable program and population outcomes.²¹⁴ Studies did not report sustainability of interventions. We found no additional information on applicability and sustainability of interventions in the gray literature.

3.2.9. Study Funding Information

The biggest funder of the included studies was government (55% [90/163]), followed by multiple funding sources (11% [18/163]), foundations (9% [15/163]), academic (5% [9/163]), and nonprofit (5% [9/163]). Self-funded work by healthcare systems was not reported. Fourteen percent (22/193) of studies did not report funding source.

3.3.1. Study Setting and Delivery Personnel

Figure 7 shows a bubble plot displaying all included studies by intervention type across study settings and delivery personnel. Interventions were implemented in a wide array of settings. Because disparity types and causes can be many and varied, including social determinants of health, the settings capture a continuum of public health to highly specialized medical care. Some categories for study settings might overlap. Most studies were carried out in clinic-based settings. Ownership or size of clinics vary from large health systems to community-based nonprofits. Federally qualified health centers (FQHCs) receive federal funding to provide comprehensive health services to underserved populations, which means they might conceptually overlap with clinics, while also potentially providing hospital or specialty care. Community-based settings were used for strategies that reach out to the patient communities, such as interventions based in churches, local libraries, or community centers. State or large city governments may provide preventive or other health services through public health systems. Other settings may include communication platforms such as telehealth, websites, mobile platforms, phones, or mailings. Multiple settings represent studies in more than one setting.

Within the above settings, interventions to address disparities were delivered by a wide array of personnel. When chosen for their ability to represent or reach patient populations, personnel are even more varied, with a range of titles and job descriptions provided by study authors, including peer/lay navigators drawn directly from the target population, peer navigators recruited as employees, community health educators, and community health workers. Several studies used researchers and/or administrative staff to conduct tasks related to the new intervention. Some studies used “other” delivery personnel and/or multiple delivery personnel. The “other” delivery personnel category represents studies that did not involve a delivery personnel but used some form of mobile or electronic tools to deliver interventions such as e-referral systems, interactive kiosk-delivered education, mobile gaming, smart phone apps, registry appointment scheduling systems, entertainment-education decision aids, social media, and electronic dashboards. Multiple delivery personnel category represents studies that comprise more than one delivery personnel category (such as a combination of patient navigators and clinicians).¹²² The provider/clinician delivery personnel category included physicians, nurses, and pharmacists.

Self-management support interventions were mostly delivered by clinicians in the clinic and FQHC settings.^{34, 37, 50, 76, 91, 117}

Prevention/lifestyle support interventions were also commonly delivered by clinicians in community-based, hospital, FQHC, and nonprofit system settings.^{30, 36, 40, 168, 184}

Patient navigation interventions were mostly delivered by peer navigators employed by the healthcare organization, particularly in community-based and hospital settings.^{48, 69, 75, 130, 145, 167, 173}

Care coordination was mainly delivered by community health workers in clinic settings.^{28, 47, 52, 101, 102, 195}

System level QI interventions were commonly delivered by “multiple” delivery personnel in clinic, hospital, FQHC, and public health system settings.^{28, 47, 52, 101, 102, 195}

Patient education interventions were mainly delivered by peer or lay community outreach workers in community-based and “other” settings (including mailings and phone call),^{176, 188, 190} and researcher or administrative staff in clinic and hospital settings.^{53, 74, 107}

Collaborative care model interventions were mainly delivered by multiple delivery personnel in FQHC settings,^{84, 144, 148} followed by clinic,¹³¹ community-based,¹²⁹ and hospital settings.⁷²

Comprehensive system level change interventions were delivered by clinicians and “multiple” delivery personnel in clinic settings,^{59, 114, 155, 163} and clinicians and “other” delivery personnel in public healthcare settings.^{54, 177}

M-Health single component interventions were delivered by “other” delivery personnel in clinic and “other” settings,^{26, 51, 192, 196} providers/clinicians in clinic settings,⁷⁰ and researcher or administrative staff in FQHC settings.⁸⁶

Transition of care interventions were delivered by clinicians in clinic, hospital, and nonprofit system setting.^{31, 82, 118}

EHR-based interventions were delivered by clinicians and “other” delivery personnel (an e-referral system) in clinic settings.^{35, 60}

Figure 7

Intervention type by setting and delivery personnel. Note: All the studies identified in our evidence map are presented in the bubble plot. Each bubble represents one study. Bubble size reflects the participant sample size. Smaller bubbles indicate smaller (more...)

3.3.2. Race/Ethnicity and Chronic Condition

Figure 8 shows a bubble plot displaying all included studies by intervention type across populations and chronic conditions. Each bubble represents one study, and the size of the bubble represents the study sample size for intervention type and chronic condition. The color of the bubble represents the race/ethnic group as presented in the literature.

Of the studies that included a single race/ethnic group, African Americans/Blacks accounted for the highest proportion (28%), followed by the Hispanics/Latinos (20%), then Asians (6%). Only two studies (1%) included exclusively American Indian/Alaskan Native people.^{88, 196} About 45 percent of included studies enrolled participants from more than one racially/ethnically minoritized group or enrolled racially/ethnically minoritized people and other groups—categorized as “multiple race/ethnic group” in this Brief. This multiple race/ethnic group category included African Americans/Blacks, Hispanics/Latinos, Asians, American Indians/Alaskan Natives, and whites.^{25, 32, 33, 36, 37, 39, 40, 42, 44–46, 53–56, 59, 61, 63–70, 72, 73, 76, 78, 82, 83, 85, 90, 92, 93, 95, 97, 123–126, 129, 132, 136, 137, 139, 144, 145, 147, 149, 152, 153, 156, 159–167, 169–171, 174, 177, 178, 190–192} Seven percent (11/163) of studies enrolled Asians as part of the “multiple race/ethnic group” category,^{25, 37, 39, 40, 83, 85, 90, 123, 132, 174, 177} and 4 percent (6/163) of studies enrolled American Indians/Alaskan Natives as part of the “multiple race/ethnic group” category.^{39, 40, 59, 123, 132, 174}

Cancer accounted for the highest exclusively studied chronic condition (29% [47/163]), followed by diabetes (20% [32/163]), then hypertension (13% [22/163]), HIV (11% [18/163]), cardiovascular diseases (7% [12/163]), mental health (4% [6/163]), and asthma (3% [5/163]). Multiple chronic conditions category represents studies that examine more than one category of chronic condition. The “other chronic conditions” category represents chronic conditions that were reported in only one or two studies, and therefore too few to represent a unique category in our evidence map including liver disease,¹⁰⁷ metabolic syndrome,¹⁷² chronic obstructive pulmonary disease (COPD),¹⁷⁴ chronic pain not related to cancer,¹⁷⁸ kidney disease,^{177, 190} or studies where study authors noted that chronic conditions were broadly examined but did not report specific chronic conditions.⁸⁸

Multiple chronic conditions and “other chronic conditions” categories accounted for ten percent (16/163) and four percent (7/163) of studies, respectively.

Self-management support interventions encompassed all chronic condition categories presented in this Brief. Self-management support interventions were mainly focused on diabetes in “multiple race/ethnic groups.”^{92, 93, 124, 132} Overall, across the chronic conditions, self-management support was mostly focused on “multiple race/ethnic groups”,^{37, 42, 65, 66, 76, 92, 93, 95, 124, 132, 136, 139, 159, 165, 170, 171, 178} followed by African Americans/Blacks.^{34, 38, 41, 50, 77, 91, 117, 135, 141, 142, 175, 189}

Patient navigation interventions were focused on asthma,²⁹ cancer,^{48, 69, 75, 81, 119, 122, 127, 130, 145, 162, 173} diabetes,^{97, 150, 183} HIV,^{57, 61, 167} mental health,⁵⁸ and “other chronic conditions.”¹⁷⁴ Patient navigation interventions were mostly focused on cancer in “multiple race/ethnic groups”,^{61, 69, 97, 145, 162, 167, 174} African Americans/Blacks,^{29, 48, 57, 58, 122, 130} and Asians.^{81, 119, 173} Overall, across the chronic conditions, patient navigation was mostly focused on “multiple race/ethnic groups,”^{61, 69, 97, 145, 162, 167, 174} followed by African Americans/Blacks.^{29, 48, 57, 58, 122, 130}

Prevention/lifestyle support interventions were focused on cancer,^{49, 87, 168} cardiovascular diseases,^{67, 152, 156} diabetes,^{40, 111, 115, 125, 185} HIV,^{36, 68, 154} hypertension,^{184, 194} “multiple chronic conditions”,^{23, 30} and “other chronic conditions”.¹⁷² Prevention/lifestyle support interventions were mostly focused on cardiovascular diseases in “multiple race/ethnic groups”.^{67, 152, 156} Overall, across the chronic conditions, prevention/lifestyle support was mostly focused on “multiple race/ethnic groups”^{36, 40, 67, 68, 125, 152, 156} followed by African Americans/Blacks.^{23, 115, 154, 168, 172, 184}

Care coordination interventions were focused on asthma,²⁸ cancer,⁷¹ cardiovascular diseases,¹⁹⁵ diabetes,^{44, 47, 52, 104, 137, 151, 161} and “multiple chronic conditions”.^{32, 101, 102, 106} Care coordination interventions were mostly focused on diabetes in “multiple race/ethnic groups”.^{44, 47, 52, 104, 137, 151, 161} Overall, across the chronic conditions, care coordination was mostly focused on “multiple race/ethnic groups”,^{32, 44, 137, 161} and African Americans/Blacks.^{28, 101, 102, 104, 106, 151, 195}

System level QI interventions were focused on cancer,^{63, 105, 187} cardiovascular diseases,^{39, 64} diabetes,¹⁹¹ HIV,^{56, 166} and hypertension.^{33, 85, 99, 121, 153} System level QI interventions were mainly focused on hypertension in “multiple race/ethnic groups”.^{33, 85, 153} Overall, across the chronic conditions, system level QI was mostly focused on “multiple race/ethnic groups”,^{33, 39, 56, 63, 64, 85, 153, 166, 191} followed by Hispanics/Latinos.^{99, 105, 187}

Patient education interventions were focused on asthma,²⁴ cancer,^{43, 53, 55, 74, 83, 143, 146, 176, 188} and “other chronic conditions”.^{107, 190} Patient education interventions were mostly focused on cancer in “multiple race/ethnic groups”.^{53, 55, 83, 190} Overall, across the chronic conditions, patient education was mostly focused on “multiple race/ethnic groups”,^{53, 55, 83, 190} followed by African Americans/Blacks and Hispanics/Latinos.^{24, 43, 74, 107, 143, 146, 188}

Collaborative care model interventions were focused on cancer,⁷³ diabetes,^{84, 131, 164} hypertension,⁷² and “multiple chronic conditions”.^{144, 148} Collaborative care model interventions were mostly focused on diabetes in African Americans/Blacks,¹³¹ Hispanics/Latinos,⁸⁴ and “multiple race/ethnic groups”,¹⁶⁴ and mental health in “multiple race/ethnic groups”^{129, 169} and Hispanics/Latinos.¹⁰⁰ Overall, across the chronic conditions, collaborative care model was mostly focused on “multiple race/ethnic groups”.^{72, 73, 129, 144, 164, 169}

Comprehensive system level change interventions were focused on hypertension,^{114, 155, 163} cardiovascular diseases,⁵⁴ “multiple chronic conditions,”⁵⁹ and “other chronic conditions”.^{88, 177} Comprehensive system level change interventions were mostly focused on hypertension in Asians,¹¹⁴ Hispanics/Latinos,¹⁵⁵ and “multiple race/ethnic groups”.¹⁶³ Overall, across the chronic conditions, comprehensive system level change was mostly focused on “multiple race/ethnic groups”.^{54, 59, 163, 177}

M-Health single component interventions were focused on cancer in “multiple race/ethnic groups”⁷⁰ and American Indians/Alaskan Natives,¹⁹⁶ HIV in Hispanics/Latinos²⁶ and “multiple race/ethnic groups”,¹⁹² and hypertension in Hispanics.^{51, 86}

Transition of care interventions were focused on HIV in African Americans/Blacks,¹¹⁸ hypertension in “multiple race/ethnic groups”,⁸² and “multiple chronic conditions” in African Americans/Blacks.³¹

EHR-based interventions were focused on hypertension in Hispanics/Latinos,³⁵ and HIV in “multiple race/ethnic groups”.⁶⁰

Figure 8

Intervention type by race/ethnicity and chronic disease. Note: All the studies identified in our evidence map are presented in the bubble plot. Each bubble represents one study. Bubble size reflects the participant sample size. Smaller bubbles indicate (more...)