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1.  Interpersonal Processes of Care Survey: Patient-Reported Measures for Diverse Groups 
Health Services Research  2007;42(3 Pt 1):1235-1256.
To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ethnic groups that allows reliable, valid, and unbiased comparisons across these groups.
Data Source/Data Collection
Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) (N = 1,664).
Study Design/Methods
In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups.
Principal Findings
The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability.
The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities.
PMCID: PMC1955252  PMID: 17489912
Quality of care; race; ethnicity; measurement; measurement invariance; factorial invariance; physician-patient communication; physician-patient interaction
2.  Online Advertising to Reach and Recruit Latino Smokers to an Internet Cessation Program: Impact and Costs 
Tobacco cessation among Latinos is a public health priority in the United States, particularly given the relatively high growth of this population segment. Although a substantial percentage of American Latinos use the Internet, they have not engaged in Web-based cessation programs as readily as other racial/ethnic subgroups. A lack of culturally specific advertising efforts may partly explain this disparity.
Phase I of this study focused on the development of four Spanish-language online banner advertisements to promote a free Spanish-language smoking cessation website ( Phase II examined the relative effectiveness of the four banner ads in reaching and recruiting Latino smokers to the cessation website.
In Phase I, 200 Spanish-speaking Latino smokers completed an online survey to indicate their preference for Spanish-language banner ads that incorporated either the cultural value of family (familismo) or fatalism (fatalismo). Ads included variations on message framing (gain vs loss) and depth of cultural targeting (surface vs deep). In Phase II, a Latin square design evaluated the effectiveness of the four preferred ads from Phase I. Ads were systematically rotated across four popular Latino websites (MySpace Latino, MSN Latino, MiGente, and Yahoo! en Español) over four months from August to November 2009. Tracking software recorded ad clicks and registrants on the cessation website. Negative binomial regression and general linear modeling examined the main and interacting effects of message framing and depth of cultural targeting for four outcomes: number of clicks, click-through rate, number of registrants, and cost per registrant.
In Phase I, smokers preferred the four ads featuring familismo. In Phase II, 24,829,007 impressions were placed, yielding 24,822 clicks, an overall click-through rate of 0.10%, and 500 registrants (2.77% conversion rate). Advertising costs totaled US $104,669.49, resulting in an overall cost per click of US $4.22 and cost per registrant of US $209.34. Website placement predicted all four outcomes (all P values < .01). Yahoo! en Español yielded the highest click-through rate (0.167%) and number of registrants (n = 267). The message framing and cultural targeting interaction was not significant. Contrary to hypotheses, loss-framed ads yielded a higher click-through rate than gain-framed ads (point estimate = 1.08, 95% CI 1.03 1.14, P = 0.004), and surface-targeted ads outperformed deep-targeted ads for clicks (point estimate = 1.20, 95% CI 1.13 1.28, P < .001), click-through rate (point estimate = 1.22, 95% CI 1.16 1.29, P < .001), and number of registrants (point estimate = 2.73, 95% CI 2.14 3.48, P < .001).
Online advertising can be an effective and cost-efficient strategy to reach and engage Spanish-speaking Latino smokers in an evidence-based Internet cessation program. Cultural targeting and smoking-relevant images may be important factors for banner ad design. Online advertising holds potential for Web-based cessation program implementation and research.
PMCID: PMC3510691  PMID: 22954502
Internet; smoking cessation; recruitment; Hispanic/Latino; advertising
3.  Ethnic Differences in Decisional Balance and Stages of Mammography Adoption 
Behavioral theories developed through research with mainstream, English-speaking populations have been applied to ethnically diverse and underserved communities in the effort to eliminate disparities in early breast cancer detection. This study tests the validity of the transtheoretical model (TTM) decisional balance measure and the application of the TTM stages of change in a multiethnic, multilingual sample. A random sample of 1,463 Filipino, Latino, African American, Chinese, and White women aged 40 to 74 completed a phone survey of mammography beliefs and practices. Consistent with the TTM and independent of ethnicity, decisional balance was associated with mammography stage in all five ethnic groups when controlling for socioeconomic and other factors. In addition, having private insurance and a regular physician and being a long-time resident in the United States were positively associated with mammography maintenance. The application of the TTM for mammography is supported in a multiethnic and multilingual sample.
PMCID: PMC2939724  PMID: 16891624
attitudes; ethnicity; stages of mammography adoption; access; decisional balance
4.  Interpersonal Processes of Care and Patient Satisfaction: Do Associations Differ by Race, Ethnicity, and Language? 
Health services research  2009;44(4):1326-1344.
Describe association of patient satisfaction with interpersonal processes of care (IPC) by race/ethnicity.
Data Sources/Study Setting
Interview with 1,664 patients (African Americans, English- and Spanish-speaking Latinos, and non-Latino Whites).
Study Design/Methods
Cross-sectional study of seven IPC measures (communication, patient-centered decision making, and interpersonal style) and three satisfaction measures (satisfaction with physicians, satisfaction with health care, and willingness to recommend physicians). Regression models explored associations, controlling for patient characteristics.
Principal Findings
In all groups: patient centered-decision making was positively associated with satisfaction with physicians (B=0.10, p<.0001) and health care (B=0.07, p<.001), and “recommend physicians” (OR=1.23, 95% CI 1.06, 1.43); discrimination was negatively associated with satisfaction with physicians (B=0.09, p<.05) and health care (B=0.17, p<.001). Unclear communication was associated with less satisfaction with physicians among Spanish-speaking Latinos. Explaining results was positively associated with all satisfaction outcomes for all groups with one exception (no association with satisfaction with physicians for Latino Spanish-speakers). Compassion/respect was positively associated with all outcomes for all groups with two exceptions (no association with satisfaction with health care among English-speaking Latinos and Whites).
All IPC measures were associated with at least one satisfaction outcome for all groups except for unclear communication.
PMCID: PMC2714869  PMID: 19490162
patient satisfaction; patient-physician communication; interpersonal care; race; ethnicity
5.  Interpersonal Processes of Care and Patient Satisfaction: Do Associations Differ by Race, Ethnicity, and Language? 
Health Services Research  2009;44(4):1326-1344.
Describe association of patient satisfaction with interpersonal processes of care (IPC) by race/ethnicity.
Data Sources/Study Setting
Interview with 1,664 patients (African Americans, English- and Spanish-speaking Latinos, and non-Latino Whites).
Study Design/Methods
Cross-sectional study of seven IPC measures (communication, patient-centered decision making, and interpersonal style) and three satisfaction measures (satisfaction with physicians, satisfaction with health care, and willingness to recommend physicians). Regression models explored associations, controlling for patient characteristics.
Principal Findings
In all groups: patient-centered decision making was positively associated with satisfaction with physicians (B=0.10, p<.0001) and health care (B=0.07, p<.001), and “recommend physicians” (OR=1.23, 95 percent CI 1.06, 1.43); discrimination was negatively associated with satisfaction with physicians (B=0.09, p<.05) and health care (B=0.17, p<.001). Unclear communication was associated with less satisfaction with physicians among Spanish-speaking Latinos. Explaining results was positively associated with all satisfaction outcomes for all groups with one exception (no association with satisfaction with physicians for Latino Spanish-speakers). Compassion/respect was positively associated with all outcomes for all groups with two exceptions (no association with satisfaction with health care among English-speaking Latinos and Whites).
All IPC measures were associated with at least one satisfaction outcome for all groups except for unclear communication.
PMCID: PMC2714869  PMID: 19490162
Patient satisfaction; patient–physician communication; interpersonal care; race; ethnicity
6.  Unequal Burden of Disease, Unequal Participation in Clinical Trials: Solutions from African American and Latino Community Members 
Health and social work  2013;38(1):29-38.
African Americans and Latinos are underrepresented in clinical trials. The purpose of this study was to elicit solutions to participation barriers from African Americans and Latinos. Fifty-seven adults (32 African Americans, 25 Latinos) ages 50 years and older participated. The Institute of Medicine's Unequal Treatment conceptual framework was used. Six racially/ethnically homogenous focus groups were conducted at five sites in three counties. Themes within groups and cross-cutting themes were identified. The NVIVO program was used for data classification. The data were reviewed for final coding and consensus. Shared solutions included addressing costs, recruiting in community contexts, conducting community and individualized patient education, and sharing patient safety information. Participants were unanimously in favor of clinical trials navigation recruitment interventions. Solutions specific to African Americans included diversifying research teams, recognizing past research abuses, and increasing community trust. Solutions specific to Latinos included providing low-literacy materials, providing Spanish-speaking clinicians and advocates, and clarifying that immigration status would neither be documented nor prevent participation. Solutions from African Americans and Latinos reflect their cultural backgrounds and historical experiences. The results suggest the importance of developing a tailored, barriers-focused navigation intervention to improve participation among diverse racial and ethnic populations.
PMCID: PMC3943359  PMID: 23539894
African American; clinical trials; Latino; solutions; underrepresentation
7.  Measuring the need for medical care in an ethnically diverse population. 
Health Services Research  1996;31(5):551-571.
OBJECTIVE: To examine measures of need for health care and their relationship to utilization of health services in different racial and ethnic groups in California. DATA SOURCE: Telephone interviews obtained by random-digit dialing and conducted between April 1993 and July 1993 in California, with 7,264 adults (ages 18-64): 601 African Americans, 246 Asians, 917 Latinos interviewed in English; 1,045 Latinos interviewed in Spanish; and 4,437 non-Latino whites. STUDY DESIGN: A cross-sectional survey was conducted from a stratified, probability telephone sample. DATA COLLECTION: Interviews collected self-reported indicators of need for health care: self-rated health, activity limitation, major chronic conditions, need for ongoing treatment, bed days, and prescription medication. The outcome was self-reported number of physician visits in the previous three months. PRINCIPAL FINDINGS: Compared to whites, one or more of the other ethnic groups varied significantly (p < .05) on each of the six need-for-care measures after adjustment for health insurance, age, sex, and income. Latinos interviewed in Spanish reported lower percentages and means on five of the need measures but the highest percentage with fair or poor health (32 percent versus 7 percent in whites). Models regressing each need measure on the number of outpatient visits found significant interactions of ethnic group with need compared to whites. After adjustment for insurance and demographics, the estimated mean number of visits in those with the indicator of need was consistently lower in Latinos interviewed in Spanish, but the differences among the other ethnic groups varied depending on the measure used. CONCLUSION: No single valid estimate of the relationship between need for health care and outpatient visits was found for any of the six indicators across ethnic groups. Applying need adjustment to the use of health care services without regard for ethnic variability may lead to biased conclusions about utilization.
PMCID: PMC1070141  PMID: 8943990
8.  Factors Influencing Physician-Referrals of Patients to Clinical Trials 
Initial trials in the NIH Parkinson’s Disease (PD) network (NET-PD) included 91% Caucasian Non-Latino patients although PD is thought to be as common among African Americans and Latinos. Our purpose was to assess physicians’ attitudes and beliefs about patient-recruitment, particularly minorities, into clinical trials.
We surveyed 200 physicians from areas near the NET-PD clinics with ≥40% African Americans or Latinos. Physicians were asked about attitudes toward research, likelihood of referring patients to PD trials, and past research participation and administered the Trust in Medical Researchers Scale (TIMRS). Using logistic regressions we identified physician characteristics associated patient-referral to clinical trials.
The TIMRS was lower among African American physicians and physicians with high proportions of minority patients. Likelihood of trial referral was associated with previous referral to trials (OR 4.24, 95% CI 2.09–8.62) and higher TIMRS (OR 1.06, 95% CI 1.001–1.12). TIMRS results were similar among physicians not previously referring to trials.
Study results emphasize the importance of developing a trusting relationship with local physicians if investigators expect these physicians to refer their patients to clinical trials. The trust-related barriers for minority-serving physicians, regardless of their own race/ethnicity, seem to mirror the trust-related issues for their minority patients.
PMCID: PMC2787404  PMID: 19024226
trust; patient recruitment; clinical trial
9.  Adherence to Cardiovascular Disease Medications: Does Patient-Provider Race/Ethnicity and Language Concordance Matter? 
Journal of General Internal Medicine  2010;25(11):1172-1177.
Patient–physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient–physician communication.
To examine the association of patient race/ethnicity and language and patient–physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system.
We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient and physician race/ethnicity and language on adherence to CVD medications, after controlling for patient and physician characteristics.
Ten percent of African American, 11 % of Hispanic, 63% of Asian, and 47% of white patients had same race/ethnicity physicians. 24% of Spanish-speaking patients were linguistically concordant with their physicians. African American (46%), Hispanic (49%) and Asian (52%) patients were significantly less likely than white patients (58%) to be in good adherence to all of their CVD medications (p < 0.001). Spanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p < 0.001). Race concordance for African American patients was associated with adherence to all their CVD medications (53% vs. 50%, p < 0.05). Language concordance was associated with medication adherence for Spanish-speaking patients (51% vs. 45%, p < 0.05).
Increasing opportunities for patient–physician race/ethnicity and language concordance may improve medication adherence for African American and Spanish-speaking patients, though a similar effect was not observed for Asian patients or English-proficient Hispanic patients.
PMCID: PMC2947630  PMID: 20571929
diabetes; racial/ethnic and linguistic health disparities; medication adherence; cardiovascular risk factor control; race/ethnic and language concordance; racial/ethnic minority health; medical workforce diversity
10.  Are Latinos Less Satisfied with Communication by Health Care Providers? 
To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white).
A random sample of patients receiving medical care from a physician group association concentrated on the West Coast was studied. A total of 7,093 English and Spanish language questionnaires were returned for an overall response rate of 59%. Five questions asking patients to rate communication by their health care providers were examined in this study. All five questions were administered with a 7-point response scale.
We estimated the associations of satisfaction ratings with language (English vs Spanish) and ethnicity (white vs Latino) using ordinal logistic models, controlling for age and gender. Latinos responding in Spanish (Latino/Spanish) were significantly more dissatisfied compared with Latinos responding in English (Latino/English) and non-Latino whites responding in English (white) when asked about: (1) the medical staff listened to what they say (29% vs 17% vs 13% rated this “very poor,”“poor,” or “fair”; p < .01); (2) answers to their questions (27% vs 16% vs 12%; p < .01); (3) explanations about prescribed medications (22% vs 19% vs 14%; p < .01); (4) explanations about medical procedures and test results (36% vs 21% vs 17%; p < .01); and (5) reassurance and support from their doctors and the office staff (37% vs 23% vs 18%; p < .01).
This study documents that Latino/Spanish respondents are significantly more dissatisfied with provider communication than Latino/English and white respondents. These results suggest Spanish-speaking Latinos may be at increased risk of lower quality of care and poor health outcomes. Efforts to improve the quality of communication with Spanish-speaking Latino patients in outpatient health care settings are needed.
PMCID: PMC1496614  PMID: 10417598
Hispanic; Latino, satisfaction, communication; quality of care
11.  Palliative Care for Latino Patients and Their Families: “Whenever We Prayed, She Wept” 
Latinos account for 15% of the US population, a proportion projected to grow to 30% by the year 2050. Although there is tremendous diversity within this community, commonalities of language, beliefs, attitudes, and behaviors unite Latinos, making them more similar than different. For non-Latino and non-Spanish-speaking clinicians, communication barriers and cultural misunderstandings can impede the care of dying Latino patients and their families. We present the case of a young, pregnant, Spanish-speaking woman from Guatemala diagnosed with a fatal leukemia. As illustrated by this case, Latino immigrants face a number of external challenges to optimal end-of-life care: (1) geographic distance as well as political and economic realities often separate patients from their valued families; (2) undocumented immigrants are frequently uninsured, and fear of deportation may create a barrier to accessing health services; (3) language and literacy barriers; and (4) concerns about discrimination. Other Latino issues that may be more pronounced in end-of-life settings include cultural themes and religious and spiritual influences. We recommend that professional interpreters must be used for discussions about goals of care with Spanish-speaking patients and families, or when negotiating conflict between the patient, family, and the health care team. Concrete suggestions are provided for clinicians in working with interpreters, eliciting culturally-based attitudes and beliefs, and implementing universal strategies for clear health communication.
PMCID: PMC2782583  PMID: 19278947
12.  Mentorship and pursuit of academic medicine careers: a mixed methods study of residents from diverse backgrounds 
BMC Medical Education  2014;14:26.
Mentorship influences career planning, academic productivity, professional satisfaction, and most notably, the pursuit of academic medicine careers. Little is known about the role of mentoring in recruiting Black/African American and Hispanic/Latino residents into academia. The objective of this study was to assess the influence of mentoring on academic medicine career choice among a cohort of racially and ethnically diverse residents.
A strategic convenience sample of U.S. residents attending national professional conferences between March and July 2010; residents completed a quantitative survey and a subset participated in focus groups.
Of the 250 residents, 183 (73%) completed surveys and 48 participated in focus groups. Thirty-eight percent of residents were white, 31% Black/African American, 17% Asian/other, and 14% Hispanic/Latino. Most respondents (93%) reported that mentorship was important for entering academia, and 70% reported having sufficient mentorship to pursue academic careers. Three themes about mentorship emerged from focus groups: (1) qualities of successful mentorship models; (2) perceived benefits of mentorship; and (3) the value of racial/ethnic and gender concordance. Residents preferred mentors they selected rather than ones assigned to them, and expressed concern about faculty using checklists. Black/African American, Hispanic/Latino, and female residents described actively seeking out mentors of the same race/ethnicity and gender, but expressed difficulty finding such mentors. Lack of racial/ethnic concordance was perceived as an obstacle for minority mentees, requiring explanation of the context and nuances of their perspectives and situations to non-minority mentors.
The majority of residents in this study reported having access to mentors. However, data show that the lack of diverse faculty mentors may impede diverse residents’ satisfaction and benefit from mentorship relationships compared to white residents. These findings are important for residency programs striving to enhance resident mentorship and for institutions working to diversify their faculty and staff to achieve institutional excellence.
PMCID: PMC3922304  PMID: 24512599
Residents; Postgraduate; Academic careers; Career choice; Diversity; Minority; Mentorship; Mentoring; Medical education
13.  Testing a Spanish-language colorectal cancer screening decision aid in Latinos with limited English proficiency: Results from a pre-post trial and four month follow-up survey 
Compared with non-Latinos, Latinos in the US have low rates of colorectal cancer (CRC) screening and low rates of knowledge regarding CRC screening tests and guidelines. Spanish speaking Latinos have particularly low CRC screening rates and screening knowledge. Our purpose was twofold: (1) to evaluate the effect of a computer-based, Spanish-language CRC screening decision aid on screening knowledge, intent to obtain screening, and screening self-efficacy in a community sample of Latinos with limited English proficiency (LEP); and (2) to survey these decision aid viewers at four months to determine their rates of CRC discussions with a health care provider as well as their rates of screening test completion.
We recruited 50-75 year old Latinos with LEP who were not current with CRC. Participants screening viewed a 14 minute multimedia decision aid that addresses CRC screening rationale, recommendations, and options. We conducted an uncontrolled (pre-post) study in which we assessed screening knowledge, self-efficacy, and intent at baseline and immediately after decision aid viewing. We also conducted a follow-up telephone survey of participants at four months to examine rates of patient-provider screening discussions and test completion.
Among n = 80 participants, knowledge scores increased from 20% (before) to 72% (after) decision aid viewing (absolute difference [95%CI]: 52% [46, 59]). The proportion with high screening self-efficacy increased from 67% to 92% (25% [13, 37]); the proportion with high screening intent increased from 63% to 95% (32% [21, 44]). We reached 68 (85%) of 80 participants eligible for the follow-up survey. Of these 36 (53%) reported discussing screening with a provider and 13 (19%) completed a test.
Viewing a Spanish-language decision aid increased CRC screening knowledge, self-efficacy, and intent among Latinos with LEP. Decision aid viewing appeared to promote both CRC screening discussions with health care providers and test completion. The decision aid may be an effective tool for promoting CRC screening and reducing screening disparities in this population.
PMCID: PMC3483183  PMID: 22691191
Decision aid; Latinos; Limited English proficiency; Colorectal cancer screening
14.  Chronic Disease Self-Management and Health Literacy in Four Ethnic Groups 
Journal of health communication  2012;17(0 3):67-81.
Research from several fields has explored health literacy as a multidimensional construct. The authors’ multimethod study, “The Impact of Cultural Differences on Health Literacy and Chronic Disease Outcomes,” assessed health literacy and chronic disease self-management among 296 patients from four ethnic groups (Vietnamese, African American, White, Latino) at a Massachusetts community health center between 2006 and 2010. Health literacy was assessed using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), and the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA) measures. Qualitative research methods, including in-depth interviews (n = 34), home visits (n = 12), chronic disease diaries (n = 15), and focus groups (n = 47), were completed with a subset of participants. Qualitative interviews indicated a wide range of interpretations of S-TOFHLA questions in which participants substituted their own illness or health care experiences for the abstract examples offered in the instrument, at times leading to incorrect responses. Situating these responses in a broader social and cultural context, this article describes examples of the wide range of chronic disease self-management abilities among participants with limited education and/or low health literacy. It also discusses the culturally variable health beliefs identified among participants interviewed that may play important roles in their chronic disease self-management practices.
PMCID: PMC3615891  PMID: 23030562
15.  Older Adult Perspectives on Physical Activity and Exercise: Voices From Multiple Cultures 
Preventing Chronic Disease  2004;1(4):A09.
Increasing physical activity is a goal of Healthy People 2010. Although the health benefits of physical activity are documented, older adults are less physically active than any other age group. The purpose of this study was to examine barriers and facilitators to physical activity and exercise among underserved, ethnically diverse older adults.
Seventy-one older adults were recruited through community agencies to participate in seven ethnic-specific focus groups: American Indian/Alaska Native, African American, Filipino, Chinese, Latino, Korean, and Vietnamese. Groups were conducted in the participants' primary language and ranged in size from 7–13 participants. Mean age was 71.6 years (range from 52 to 85 years; SD ± 7.39). Professional translators transcribed audiotapes into the language of the group and then translated the transcript into English. Transcripts were systematically reviewed using content analysis.
Suggested features of physical activity programs to enhance participation among ethnically diverse minority older adults included fostering relationships among participants; providing culture-specific exercise; offering programs at residential sites; partnering with and offering classes prior to or after social service programs; educating families about the importance of physical activity for older adults and ways they could help; offering low- or no-cost classes; and involving older adults in program development. Walking was the exercise of choice across all ethnic groups. Health served as both a motivator and a barrier to physical activity. Other factors influencing physical activity were weather, transportation, and personal safety.
Findings from this study suggest strategies for culture-specific programming of community-based physical activity programs.
PMCID: PMC1277949  PMID: 15670441
16.  Co-occurrence of mental and physical illness in U.S. Latinos 
This study describes the prevalence of comorbid physical and mental health problems in a national sample of U.S. Latinos. We examined the co-occurrence of anxiety and depression with prevalent physical chronic illnesses in a representative sample of Latinos with national origins from Mexico, Cuba, Puerto Rico, and other Latin American countries.
We used data on 2,554 Latinos (75.5% response rate) ages 18 years and older from the National Latino and Asian American Study (NLAAS). The NLAAS was based on a stratified area probability sample design, and the sample came from the 50 states and Washington, DC. Survey questionnaires were delivered both in person and over the telephone in multiple languages, including Spanish and English. Psychiatric disorders were assessed using the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI). Physical chronic illness was assessed by self-reported history.
Puerto Ricans had the highest prevalence of meeting criteria for any comorbid psychiatric disorder (more than one disorder). Puerto Ricans had the highest prevalence (22%) of subject-reported asthma history, while Cubans had the highest prevalence (33%) of cardiovascular disease. After accounting for age, sex, household income, number of years in the U.S., immigrant status, and comorbid anxiety and depression, anxiety was associated with diabetes and cardiovascular disease, in the entire sample. Depression and comorbid anxiety and depression were associated with asthma but not with other physical diseases, in the entire sample. The relationship between chronic physical and mental illness was not confounded by immigration status or number of years in the U.S.
Despite previous findings that link acculturation with both chronic physical and mental illness, this study does not find that number of years in the US nor nativity explain the prevalence of psychiatric-medical comorbidities. This study demonstrates the importance of considering psychiatric and medical comorbidity among specific ethnic groups, as different patterns emerge than when using aggregate ethnic measures. Research is needed on both the pathways and the mechanisms of comorbidity for the specific Latino groups.
PMCID: PMC2791952  PMID: 17013767
17.  Developing Culturally Sensitive Dementia Caregiver Interventions: Are We There Yet? 
Despite evidence of ethnic differences in family caregivers’ experiences, the extent to which caregiver interventions are culturally tailored to address these differences is unknown. A systematic review of literature published from 1980–2009 identified: differences in caregiving experiences of African American, Latino and Chinese American caregivers; psychosocial support interventions in these groups; and cultural tailoring of interventions. Ethnic differences in caregiving occurred at multiple levels (intrapersonal, interpersonal, environmental) and in multiple domains (psychosocial health, life satisfaction, caregiving appraisals, spirituality, coping, self-efficacy, physical functioning, social support, filial responsibility, familism, views toward elders, use of formal services and health care). Only 18 of 47 intervention articles reported outcomes by caregiver ethnicity. Only 11 reported cultural tailoring; 8 were from the REACH initiative. Cultural tailoring addressed: familism, language, literacy, protecting elders, and logistical barriers. Results suggest that more caregiver intervention studies evaluating systematically the benefits of cultural tailoring are needed.
PMCID: PMC3581148  PMID: 20508244
cultural sensitivity; cultural competence; dementia caregivers; Latinos; African Americans; Chinese Americans; support interventions
18.  The Relationship Between Expectations for Aging and Physical Activity Among Older Adults 
New strategies to increase physical activity among sedentary older adults are urgently needed.
To examine whether low expectations regarding aging (age-expectations) are associated with low physical activity levels among older adults.
Cross-sectional survey.
Six hundred and thirty-six English- and Spanish-speaking adults aged 65 years and above attending 14 community-based senior centers in the Los Angeles region. Over 44% were non-Latino whites, 15% were African American, and 36% were Latino. The mean age was 77 years (range 65 to 100).
Self-administered written surveys including previously tested measures of age-expectations and physical activity level in the previous week.
Over 38% of participants reported <30 minutes of moderate-vigorous physical activity in the previous week. Older adults with lower age-expectations were more likely to report this very low level of physical activity than those with high age-expectations, even after controlling for the independent effect of age, sex, ethnicity, level of education, physical and mental health–related quality of life, comorbidity, activities of daily living impairment, depressive symptoms, self-efficacy, survey language, and clustering at the senior center. Compared with the quintile of participants having the highest age-expectations, participants with the lowest quintile of age-expectations had an adjusted odds ratio of 2.6 (95% confidence intervals: 1.5, 4.5) of reporting <30 minutes of moderate-vigorous physical activity in the previous week.
In this diverse sample of older adults recruited from senior centers, low age-expectations are independently associated with very low levels of physical activity. Harboring low age-expectations may act as a barrier to physical activity among sedentary older adults.
PMCID: PMC1490218  PMID: 16191137
attitude to health; aged; exercise; survey; health behavior
19.  Hablamos Juntos (Together We Speak): Interpreters, Provider Communication, and Satisfaction with Care 
Journal of General Internal Medicine  2010;25(12):1282-1288.
The Hablamos Juntos—Together We Speak (HJ)—national demonstration project targeted the improvement of language access for Spanish-speaking Latinos in areas with rapidly growing Latino populations. The objective of HJ was to improve doctor-patient communication by increasing access to and quality of interpreter services for Spanish-speaking patients.
To investigate how access to interpreters for adult Spanish-speaking Latinos is associated with ratings of doctor/office staff communication and satisfaction with care.
Cross-sectional cohort study.
A total of 1,590 Spanish-speaking Latino adults from eight sites across the United States who participated in the outpatient HJ evaluation.
We analyzed two multi-item measures of doctor communication (4 items) and office staff helpfulness (2 items), and one global item of satisfaction with care by interpreter use. We performed regression analyses to control for patient sociodemographic characteristics, survey year, and clustering at the site of care.
Ninety-five percent of participants were born outside the US, 81% were females, and survey response rates ranged from 45% to 85% across sites. In this cohort of Spanish-speaking patients, those who needed and always used interpreters reported better experiences with care than their counterparts who needed but had interpreters unavailable. Patients who always used an interpreter had better adjusted ratings of doctor communication [effect size (ES = 0.51)], office staff helpfulness (ES = 0.37), and satisfaction with care (ES = 0.37) than patients who needed but did not always use an interpreter. Patients who needed and always used interpreters also reported better experiences with care in all three domains measured [doctor communication (ES = 0.30), office staff helpfulness (ES = 0.21), and satisfaction with care (ES = 0.23)] than patients who did not need interpreters.
Among adult Spanish-speaking Latinos, interpreter use is independently associated with higher satisfaction with doctor communication, office staff helpfulness, and ambulatory care. Increased attention to the need for effective interpreter services is warranted in areas with rapidly growing Spanish-speaking populations.
PMCID: PMC2988148  PMID: 20703951
doctor-patient communication; Latino population; interpreter services; immigrants; disparities; limited English proficient
20.  Patient-Physician Language Concordance: A Strategy for Meeting the Needs of Spanish-Speaking Patients in Primary Care 
The Permanente Journal  2009;13(4):79-84.
The Hispanic/Latino community increased by 58% in the last decade (1990–2000) and it is estimated that Hispanics/Latinos will be 30% of the population by 2050. Many of the Hispanic/Latino households (40%) surveyed by the census bureau in 2000 spoke Spanish. Because of its location, the Southern California Permanente Medical Group, which provides the medical services for Kaiser Permanente Southern California (KPSC) serves a large and growing Hispanic/Latino community. It is estimated that by 2010, the KPSC region will be between 30–50% Hispanic/Latino. A Spanish language task force (the task force) was created in 2006 to address the needs of the KPSC Spanish-speaking membership using primary care services. This task force examined data from a variety of sources including electronic medical databases and focus group reports from Spanish-speaking members. Using the task force findings and the literature in this area, we make recommendations to increase patient-physician language concordance in other health care settings so that organizations can effectively serve a growing Hispanic/Latino, Spanish-speaking patient population.
PMCID: PMC2911827  PMID: 20740108
21.  Prevalence of Psychiatric Illnesses among Ethnic Minority Elderly 
To compare lifetime and 12-month prevalence of DSM-IV psychiatric disorders among a national representative sample of older Latinos, Asians, African-Americans, and Afro-Caribbean to non-Latino Whites.
Cross-sectional study conducted in 2001 through 2004.
Urban and rural households in the contiguous United States.
A total of 4,245 community-dwelling residents aged 50 and older living in non-institutional settings. Data are from the NIMH Collaborative Psychiatric Epidemiology Surveys.
The World Health Organization Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Interviewers matched the cultural background and language preference of participants. Bayesian estimates compared psychiatric disorder prevalence rates among ethnic/racial groups.
After gender adjustments, older non-Latino Whites had higher lifetime rates of any depressive disorder than African-Americans but were no different than older Latinos. Older Asians and Afro-Caribbean had significantly lower lifetime rates of any depressive, anxiety, and substance use disorders than non-Latino Whites. Immigrant Asians had higher lifetime rates of GAD than the U.S.-born Asians and immigrant Latinos had higher lifetime rates of dysthymia and GAD than U. S.-born Latinos. U.S. born Latinos had higher lifetime rates of substance abuse, especially alcohol abuse, than immigrant Latinos. There were no significant differences in the rates of 12-month psychiatric disorders between non-Latino whites and ethnic/racial minorities, except that older African-Americans had higher 12-month rates of any substance use disorder compared to non-Latino Whites.
Prevalence rates vary considerably by ethnicity and race as well as by nativity for older minorities, suggesting different patterns of illness and risk.
PMCID: PMC2854540  PMID: 20374401
ethnicity; prevalence; psychiatric illness; older adults
22.  Effect of Language on Colorectal Cancer Screening Among Latinos and Non-Latinos 
Language barriers among some Latinos may contribute to the lower rates of colorectal cancer (CRC) screening between Latinos and non-Latino Whites. The purpose of this study was to examine the relationship between language and receipt of colorectal cancer screening tests among Latinos and non-Latinos using a geographically diverse, population-based sample of adults.
Cross-sectional analysis of the Behavioral Risk Factor Surveillance System (BRFSS) survey. Analysis included adults 50 years of age and older, who completed the 2006 BRFSS in a state that recorded data from English and Spanish-speaking participants.
The primary outcome measure was receipt of colorectal screening tests (fecal occult blood testing within prior 12 months and/or lower endoscopy within 10 years). Of the 99,895 respondents included in the study populations, 33% of Latinos responding-in-Spanish reported having had CRC testing, while 51% of Latinos responding-in-English and 62% of English-speaking non-Latinos reported test receipt. In multivariable analysis, compared to non-Latinos, Latinos responding-in-English were 16% less likely (OR,0.84, 95 % CI, 0.73-0.98), and Latinos responding-in-Spanish were 43% less likely to have received colorectal cancer testing (OR,0.57, 95% CI, 0.44-0.74). Additionally, compared to Latinos responding-in-English, Latinos responding-in-Spanish were 36% less likely to have received CRC testing (OR, 0.64; 95% CI, 0.48-0.84)
Latinos responding to the 2006 BRFSS survey in Spanish had a significantly lower likelihood of receiving CRC screening tests compared to non-Latinos and to Latinos responding-in-English. Based on this analysis, Spanish language use is negatively associated with CRC screening and may contribute to disparities in CRC screening.
PMCID: PMC2568081  PMID: 18708410
Colorectal cancer; Screening; Latino/Hispanic; Language; BRFSS
23.  Physician Language Ability and Cultural Competence 
We studied physician–patient dyads to determine how physician self-rated Spanish-language ability and cultural competence affect Spanish-speaking patients’ reports of interpersonal processes of care.
Questionnaire study of 116 Spanish-speaking patients with diabetes and 48 primary care physicians (PCPs) at a public hospital with interpreter services.
Primary care physicians rated their Spanish ability on a 5-point scale and cultural competence by rating: 1) their understanding of the health-related cultural beliefs of their Spanish-speaking patients; and 2) their effectiveness with Latino patients, each on a 4-point scale. We assessed patients’ experiences using the interpersonal processes of care (IPC) in diverse populations instrument. Primary care physician responses were dichotomized, as were IPC scale scores (optimal vs nonoptimal). We analyzed the relationship between language and two cultural competence items and IPC, and a summary scale and IPC, using multivariate models to adjust for known confounders of communication.
Greater language fluency was strongly associated with optimal IPC scores in the domain of elicitation of and responsiveness to patients, problems and concerns [Adjusted Odds Ratio [AOR], 5.25; 95% confidence interval [CI], 1.59 to 17.27]. Higher score on a language-culture summary scale was associated with three IPC domains – elicitation/responsiveness (AOR, 6.34; 95% CI, 2.1 to 19.3), explanation of condition (AOR, 2.7; 95% CI, 1.0 to 7.34), and patient empowerment (AOR, 3.13; 95% CI, 1.2 to 8.19)—and not associated with two more-technical communication domains.
Physician self-rated language ability and cultural competence are independently associated with patients’ reports of interpersonal process of care in patient-centered domains. Our study provides empiric support for the importance of language and cultural competence in the primary care of Spanish-speaking patients.
PMCID: PMC1492135  PMID: 15009796
cultural competence; Latino; health disparities; language barriers; communication; Hispanic; interpretation
24.  Introduction of Solid Food to Young Infants 
Maternal and Child Health Journal  2010;15(8):1185-1194.
Timing of the first introduction of solid food during infancy may have potential effects on life-long health. To understand the characteristics that are associated with the timing of infants’ initial exposure to solid foods. The 2000 National Survey of Early Childhood Health (NSECH) was a nationally representative telephone survey of 2,068 parents of children aged 4–35 months, which profiled content and quality of health care for young children. African-American and Latino families were over-sampled. Analyses in this report include bivariate tests and logistic regressions. 62% of parents reported introducing solids to their child between 4–6 months of age. African-American mothers (OR = 0.5 [0.3, 0.9]), English-speaking Latino mothers (OR = 0.4 [0.2, 0.7]), White mothers with more than high school education (OR = 0.5 [0.2, 1.0]), and mothers who breastfed for 4 months or longer (OR = 0.4 [0.3, 0.7]) were less likely to introduce solids early. Most parents (92%) of children 4–9 months of age reported that their pediatric provider had discussed introduction of solids with them since the child’s birth, and provider discussion of feeding was not associated with the timing of introduction of solids. Although most parents recall discussing the introduction of solid foods with their child’s physician, several subgroups of mothers introduce solid foods earlier than the AAP recommendation of 4–6 months. More effective discussion of solid food introduction linked to counseling and support of breastfeeding by the primary health care provider may reduce early introduction of solids.
PMCID: PMC3195680  PMID: 20842523
Early feeding; Breastfeeding; Introduction of solid foods
Ethnicity & disease  2009;19(3):352-358.
To outline the lessons learned about the use of focus groups for the multi-site, multi-ethnic longitudinal Study of Women Across the Nation (SWAN). Focus groups were designed to identify potential cultural differences in the incidence of symptoms and the meaning of transmenopause among women of diverse cultures, and to identify effective recruitment and retention strategies.
Inductive and deductive focus groups for a multi-ethnic study.
Seven community research sites across the United States conducted focus groups with six ethnic populations: African American, Chinese American, Japanese American, Mexican American, non-Hispanic white, and Puerto Rican.
Patients or Participants
Community women from each ethnic group of color.
A set of four/five focus groups in each ethnic group as the formative stage of the deductive, quantitative SWAN survey.
Main Outcome Measures
Identification of methodological advantages and challenges to the successful implementation of formative focus groups in a multi-ethnic, multi-site population-based epidemiologic study.
We provide recommendations from our lessons learned to improve the use of focus groups in future studies with multi-ethnic populations.
Mixed methods using inductive and deductive approaches require the scientific integrity of both research paradigms. Adequate resources and time must be budgeted as essential parts of the overall strategy from the outset of study. Inductive cross-cultural researchers should be key team members, beginning with inception through each subsequent design phase to increase the scientific validity, generalizability, and comparability of the results across diverse ethnic groups, to assure the relevance, validity and applicability of the findings to the multicultural population of focus.
PMCID: PMC2893220  PMID: 19769020
Focus Groups; Multi-ethnic; Menopause Transition; SWAN Study

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