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1.  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
2.  Sexually Transmitted Infection Prevalence and Behavioral Risk Factors among Latino and Non-Latino Patients Attending the Baltimore City STD Clinics 
Sexually transmitted diseases  2010;37(3):191-196.
Many studies have evaluated factors influencing STD/HIV disparities between African-American and white populations, but fewer have explicitly included Latinos for comparison.
We analyzed demographic and behavioral data captured in electronic medical records of patients first seen by a clinician in one of two Baltimore City public STD clinics between 2004 and 2007. Records from white, African-American, and Latino patients were included in the analysis.
There were significant differences between Latinos and other racial/ethnic groups for several behavioral risk factors studied, with Latino patients reporting fewer behavioral risk factors than other patients. Latinos were more likely to have syphilis, but less likely to have gonorrhea than other racial/ethnic groups. English-proficient Latina (female) patients reported higher rates of infection and behavioral risk factors than Spanish-speaking Latina patients. After adjustment for gender and behavioral risk factors, Spanish-speaking Latinas also had significantly less risk of sexually transmitted infections than did English-speaking Latinas.
These results are consistent with other studies showing that acculturation (as measured by language proficiency) is associated with increases in reported sexual risk behaviors among Latinos. Future studies on sexual risk behavior among specific Latino populations characterized by country of origin, level of acculturation, and years in the U.S. may identify further risk factors and protective factors to guide development of culturally appropriate STD/HIV interventions.
PMCID: PMC2828531  PMID: 19910863
Hispanic/Latino; sexually transmitted disease clinic; racial/ethnic disparities; acculturation; gonorrhea; chlamydia; syphilis; HIV
3.  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
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.  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
7.  Digital Technology Ownership, Usage, and Factors Predicting Downloading Health Apps Among Caucasian, Filipino, Korean, and Latino Americans: The Digital Link to Health Survey 
JMIR mHealth and uHealth  2014;2(4):e43.
Interventions using mobile health (mHealth) apps have been effective in promoting healthy lifestyle behavior change and hold promise in improving health outcomes to thereby reduce health disparities among diverse racial/ethnic populations, particularly Latino and Asian American subgroups (Filipinos and Koreans) at high risk for diabetes and cardiovascular disease. Latinos and Asian Americans are avid digital technology owners and users. However, limited datasets exist regarding digital technology ownership and use, especially among specific racial/ethnic subgroups. Such information is needed to inform development of culturally tailored mHealth tools for use with lifestyle interventions promoting healthy behaviors for these at-risk racial/ethnic populations.
The intent of the study was to examine (1) digital technology ownership and usage, and (2) factors predicting downloading health apps for Caucasian, Filipino, Korean, and Latino American subgroups.
A cross-sectional survey conducted in August 2013 through December 2013 recruited 904 participants (Caucasians n=172, Filipinos n=250, Koreans n=234, and Latinos n=248), age >18 years, from California community events, clinics, churches, and online. English, Spanish, and Korean surveys were administered via paper or online. Descriptive statistics characterized the sociodemographics and digital technology ownership/usage of the 904 participants. Differences among groups in categorical variables were examined using chi-square statistics. Logistic regression was used to determine factors predicting downloading health apps.
Overall, mean age was 44 years (SD 16.1), with 64.3% (581/904) female. Only 44.7% (404/904) of all participants reported English as their primary language (Caucasian 98.3%, 169/172; Filipino 67.6%, 169/250; Korean 9.4%, 22/234, and Latino 17.7%, 44/248. Overall, mobile phone ownership was 92.8% (839/904). Compared to all groups, Koreans were more likely to own a mobile phone (82.8%, 194/234), computer (91.4%, 214/234), or tablet (55.2%, 129/234), whereas Latinos (67.5%, 167/248; 65.3%, 162/248; 24.4%, 61/248, respectively) were least likely. Internet access via mobile phones (90.5%, 818/904) was higher than computers (78.6%, 711/904). Odds of downloading health apps increased with college (OR 2.62, 95% CI 1.44-4.80) or graduate school (OR 2.93, 95% CI 1.43-6.00) compared to some high school; and family history of heart attack (OR 2.02, 95% CI 1.16-3.51). Odds of downloading health apps were reduced with: race/ethnicity, Latino (OR 0.37, 95% CI 0.20-0.69), and Korean (OR 0.52, 95% CI 0.31-0.88) compared to Caucasians; increasing age (OR 0.96, 95% CI 0.95-0.97); and completing paper surveys (OR 0.50, 95% CI 0.34-0.75).
This survey study uniquely targeted specific racial/ethnic subgroups. Results indicated that despite a narrowing racial/ethnic “digital divide”, some disparities still exist, particularly among racial/ethnic groups with less education and whose primary language is not English. Findings will be used to inform development and evaluation of culturally tailored mHealth apps for use with interventions promoting healthy behavior change for Filipinos, Koreans, and Latinos.
PMCID: PMC4259923  PMID: 25339246
digital technology; mobile health apps; mHealth; Latinos; Filipinos; Koreans; cross-sectional survey
8.  Increased healthcare resource utilization among Latino infants with acute respiratory illness compared with other racial/ethnic groups 
The Journal of pediatrics  2013;163(4):1186-1191.
To examine healthcare resource utilization for Latino infants with acute respiratory illness compared with other racial/ethnic groups.
We studied 674 term, previously healthy infants presenting for an unscheduled healthcare visit for acute respiratory illness. The predictor variable was infant race/ethnicity, and the primary outcome was healthcare resource utilization, adjusted for age and disease severity.
The cohort was 14% Latino, 52% white, 22% African-American, and 12% other races/ethnicities. Mothers of Latino infants were 37% Spanish-speaking. Bronchiolitis severity score was higher (indicating more severe disease) in white infants (median 6.0, interquartile range 3.0–9.0, on a 0–12 point scale) versus Latinos (3.0, 1.0–6.0) and African-Americans (3.5, 1.0–6.0), p<0.001 for the comparison of all groups. Disease severity was similar between Latino and African-American infants (p=0.96). Latino infants were the group most likely to receive antibiotics (58% of Latinos, 47% of whites, 34% of African-Americans, p=0.005) and have body fluid cultures drawn. Latino infants were also more likely than African-Americans to have chest x-rays and respiratory virus rapid antigen testing (p≤0.01). Latino infants from Spanish-speaking families, compared with those from English-speaking families, had increased receipt of RSV testing (76% versus 51%, p=0.016).
Providers caring for Latino infants with acute respiratory illness ordered more antibiotics and diagnostic testing for this group, particularly compared with African-Americans, who have similar disease severity and socioeconomic disparities. This suggests that the language barrier may be a potential explanation for observed differences.
PMCID: PMC3935481  PMID: 23706603
bronchiolitis; healthcare utilization; Latino
9.  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
10.  Pediatrician Identification of Latino Children at Risk for Autism Spectrum Disorder 
Pediatrics  2013;132(3):445-453.
Latino–white disparities in age at autism spectrum disorder (ASD) diagnosis may be modified by primary care pediatrician (PCP) practices and beliefs. The objectives of this study were to assess ASD and developmental screening practices, attitudes toward ASD identification in Latino children, and barriers to ASD identification for Latino children, in a sample of 267 California PCPs.
In mail-based PCP survey, we assessed rates of bilingual general developmental and ASD screening, perceptions of parent ASD knowledge in Latino and white families, reports of difficulty assessing for ASDs in Latino and white children, and perceptions of barriers to early ASD identification for Latinos.
Although 81% of PCPs offered some form of developmental screening, 29% of PCPs offered Spanish ASD screening per American Academy of Pediatrics guidelines, and only 10% offered both Spanish general developmental and Spanish ASD screening per American Academy of Pediatrics guidelines. Most PCPs thought that Latino (English and Spanish primary family language) parents were less knowledgeable about ASDs than white parents. PCPs had more difficulty assessing ASD risk for Latino children with Spanish primary family language than for white children, even when the PCP conducted recommended ASD screening or had >25% Latino patients. The most frequent barrier to ASD identification in Latinos was access to developmental specialists.
Multiple factors in the primary care setting may contribute to delayed ASD identification for Latinos. Promoting language-appropriate screening, disseminating culturally appropriate ASD materials to Latino families, improving the specialist workforce, and providing PCP support in screening and referral of Latino children may be important ways to reduce racial and ethnic differences in care.
PMCID: PMC3876760  PMID: 23958770
autism spectrum disorder; Hispanic Americans; pediatrics; health care disparities; child development; developmental disabilities; developmental screening
11.  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
12.  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
13.  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
14.  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
15.  Race/Ethnicity, Language, and Patients' Assessments of Care in Medicaid Managed Care 
Health Services Research  2003;38(3):789-808.
Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language.
Data Sources
Data were derived from the National CAHPS ® Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000.
Data Collection
The CAHPS® data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent.
Study Design
Data were analyzed using linear regression models. The dependent variables were CAHPS ® 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health.
Principal Findings
Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities.
This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts.
PMCID: PMC1360917  PMID: 12822913
Race/ethnicity; consumer assessments; CAHPS®; patient experiences; patient reports and ratings
16.  The Role of Patient Activation on Patient–Provider Communication and Quality of Care for US and Foreign Born Latino Patients 
Journal of General Internal Medicine  2009;24(Suppl 3):534-541.
Previous research has shown positive effects of patient activation on healthcare outcomes, but there is practically no information on the generalization of these findings for Latino patients. Little data are available on whether patient activation is associated with healthcare outcomes for Latino patients and whether activation varies by language proficiency and nativity status.
We examined the levels of activation by characteristics of Latino patients (e.g. nativity, language, health status). We investigated whether patient activation relates to the quality of care received and enhanced doctor–patient communication for Latino patients.
We conducted analyses of 1,067 US born and foreign born Latinos who participated in the second wave of the PEW/RWJF Hispanic Healthcare Survey during 2008.
Participants were self-identified Latinos (18+) with a doctor visit, living in the contiguous United States who could be contacted by telephone.
US born Latinos had significantly (P < 0.001) greater patient activation scores than foreign born Latinos (75 versus 70). Latinos classified as bilingual and those reporting excellent health evidenced higher mean activation scores as compared to Spanish-speaking Latinos and those reporting fair or poor health. After adjusting for demographics, health status, other language and service use factors, patient activation was strongly associated with self-reported quality of care and better doctor–patient communication among both US and foreign born Latino respondents.
Interventions that augment patient activation could increase quality of care and improved patient–provider communication, potentially reducing health care disparities for Latinos.
PMCID: PMC2764038  PMID: 19842003
patient–provider communication; Latinos; activation; quality of care
17.  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
18.  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
19.  Psychotropic Medication Nonadherence Among United States Latinos: A Comprehensive Review of the Literature 
Psychotropic medication nonadherence is a major public health problem, but few studies have focused on Latinos. We systematically reviewed the literature on rates of and factors influencing antipsychotic, antidepressant, or mood stabilizer nonadherence among United States (US) Latinos.
Data Sources: MEDLINE and PsycINFO were searched using keywords adherence, compliance, Latino, Hispanic, psychotropic, and related terms, as well as bibliographies from relevant reviews and studies.
Study Selection: 21 studies met inclusion criteria: published since 1980 in English or Spanish; measured psychotropic medication nonadherence rates among US Latino adults.
Data Abstraction: We examined articles for study design and objective, location, population, medication type, participant demographics, adherence measure, adherence rates, and factors related to adherence.
Results and Conclusions
In studies including Latinos and other ethnic groups, mean nonadherence rates were 41%, 31%, and 43% among Latinos, Euro-Americans, and African Americans respectively, with an overall effect size of 0.64 between Latinos and Euro-Americans. In studies including only Latinos, the mean nonadherence rate was 44%. Ten of 16 studies found Latinos had significantly lower adherence rates than Euro-Americans. Risk factors for nonadherence included being monolingual Spanish speaking, lacking health insurance, experiencing barriers to quality care, and having lower socioeconomic status. Protective factors included family support and psychotherapy.
Rates of nonadherence to psychotropic medications were higher for Latinos than for Euro-Americans. Further investigation is needed into the potentially modifiable individual and societal level mechanisms of this discrepancy. Clinical and research interventions to improve adherence should be culturally appropriate and incorporate identified factors.
PMCID: PMC3222920  PMID: 19176409
20.  Still a Hard-to-Reach Population? Using Social Media to Recruit Latino Gay Couples for an HIV Intervention Adaptation Study 
Online social networking use has increased rapidly among African American and Latino men who have sex with men (MSM), making it important to understand how these technologies can be used to reach, retain, and maintain individuals in care and promote health wellness. In particular, the Internet is increasingly recognized as a platform for health communication and education. However, little is known about how primarily Spanish-speaking populations use and engage with each other through social media platforms.
We aimed to recruit eligible couples for a study to adapt “Connect ‘n Unite” (an HIV prevention intervention initially created for black gay couples) for Spanish-speaking Latino gay couples living in New York City.
In order to successfully design and implement an effective social media recruitment campaign to reach Spanish-speaking Latino gay couples for our ongoing “Latinos en Pareja” study, our community stakeholders and research team used McGuire’s communication/persuasion matrix. The matrix guided our research, specifically each marketing “channel”, targeted “message”, and target population or “receiver”. We developed a social media recruitment protocol and trained our research staff and stakeholders to conduct social media recruitment.
As a result, in just 1 month, we recruited all of our subjects (N=14 couples, that is, N=28 participants) and reached more than 35,658 participants through different channels. One of the major successes of our social media recruitment campaign was to build a strong stakeholder base that became involved early on in all aspects of the research process—from pilot study writing and development to recruitment and retention. In addition, the variety of “messages” used across different social media platforms (including Facebook, the “Latinos en Pareja” study website, Craigslist, and various smartphone applications such as Grindr, SCRUFF, and Jack’d) helped recruit Latino gay couples. We also relied on a wide range of community-based organizations across New York City to promote the study and build in the social media components.
Our findings highlight the importance of incorporating communication technologies into the recruitment and engagement of participants in HIV interventions. Particularly, the success of our social media recruitment strategy with Spanish-speaking Latino MSM shows that this population is not particularly “hard to reach”, as it is often characterized within public health literature.
PMCID: PMC4019772  PMID: 24763130
social media; online recruitment strategies; Spanish-speaking Latino men who have sex with men (MSM); Latino gay couples; Latino MSM; HIV prevention
21.  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
22.  Lower rates of emergency department injury visits among Latino children in the USA: no association with health insurance 
Injury Prevention  2006;12(4):248-252.
Background and objective
Latino children have lower rates of injury visits to emergency departments (EDs) than non‐Latino white and African American children. This study tests the hypothesis that this difference reflects health insurance status.
Secondary analysis.
Children under 19 years of age visiting EDs in the USA, sampled in the National Hospital Ambulatory Medical Care Survey of EDs (NHAMCS‐ED) from 1997 to 2001.
Main outcome measures
Rates of ED injury visits; ED injury visit rates by race/ethnicity stratified by health insurance and adjusted for other covariates; subtypes of injury visits; and procedures and hospital admissions by race/ethnicity.
Injuries accounted for >56 million, or 40.5%, of total ED visits among pediatric patients. Injury visits occurred at lower rates for Latino children (9.9 per 100 person years) than non‐Latino white and African American children (16.2 and 18.3, respectively), although total ED visit rates were similar. Regardless of health insurance status, Latino children had lower rates of injury visits than non‐Latino white and African American children. Latino children had lower rates of the three major subtypes of injury visits (sports, accidental falls, struck by/between objects). Latino children had similar rates of procedures and hospital admissions to non‐Latino white children.
Irrespective of their insurance status, Latino children have lower rates of ED injury visits in the USA than non‐Latino white children. Possible reasons for this difference include different healthcare seeking behavior or different injury patterns by race/ethnicity, but not differences in health insurance status or barriers to accessing ED care.
PMCID: PMC2586778  PMID: 16887947
child; ethnicity; health insurance; emergency department visits
23.  Distinct Beliefs, Attitudes, and Experiences of Latino Smokers: Relevance for Cessation Interventions 
Determine the extent to which Latino smokers are using effective interventions for smoking cessation, with particular focus on nicotine replacement therapy (NRT). Related aims were to explore cultural, attitudinal, knowledge, and socioeconomic variables associated with treatment use.
Cross-sectional telephone survey of two groups of Colorado adult smokers: Latinos (n = 1010) and non-Latino whites (n = 519).
Computer-assisted telephone survey in either Spanish or English. Survey addressed sociodemographic variables; smoking and cessation history; knowledge, attitudes, and beliefs about smoking and quitting; and experiences in and attitudes toward the health care setting.
Latino and non-Latino white adult Colorado residents who reported being regular smokers.
Colorado Latinos report using NRT substantially less often than do non-Latino whites residing in the state. This and other differences in the study were more pronounced in Latinos characterized as low acculturation on the basis of a language preference variable. Latinos smoke somewhat less than non-Latino whites and report lower levels of dependence. They appear to be motivated to quit but endorse attitudes and beliefs antithetical to NRT use. Health care access was lower among Latinos, and this was related to lower reports of lifetime NRT use. Receipt of recommended practitioner intervention (the “five As”) did not differ by ethnicity.
Results suggested that use of effective cessation interventions among Latinos may be enhanced by education about nicotine addiction and NRT. Policy change to increase health care access also showed promise.
PMCID: PMC3166215  PMID: 21510796
Cigarette Smoking; Hispanic Americans; Culture; Acculturation; Smoking Cessation; Prevention Research
24.  Preferences for Self-Management Support: Findings from a Survey of Diabetes Patients in Safety-Net Health Systems 
Patient education and counseling  2007;70(1):102-110.
We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals, and to assess whether demographic or disease-specific factors were associated with patient preferences. We explored the possible role of a perceived communication need in influencing interest in self-management support.
Telephone survey of a random sample of 796 English and Spanish-speaking diabetes patients (esponse rate 47%) recruited from 4 urban US public hospital systems. In multivariate models, we measured the association of race/ ethnicity, primary language, self-reported health literacy, self-efficacy, and diabetes-related factors on patients’ interest in three self-management support strategies (telephone support, group medical visits, and internet -based support). We explored the extent to which patients believed that better communication with providers would improve their diabetes control, and whether this perception altered the relationship between patient factors and self-management support acceptance.
Sixty-nine percent of respondents reported interest in telephone support, 55% in group medical visits, and 42% in internet. Compared to Non-Hispanic Whites, Spanish-speaking Hispanics were more interested in telephone support (OR 3.45, 95%CI 1.97–6.05) and group medical visits (OR 2.45, 95%CI 1.49–4.02), but less interested in internet self-management support (OR 0.56, 95%CI 0.33–0.93). African-Americans were more interested than Whites in all 3 self-management support strategies. Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits. Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider. This perceived communication benefit was independently associated with interest in self-management support (p<0.001), but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences.
Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy.
Practice Implications
Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings.
PMCID: PMC2745943  PMID: 17997264
diabetes; communication; health literacy; telephone care; group medical visits; racial/ethnic minority; self-management; disparities
25.  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

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