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1.  Contributors to self-reported health in a racially and ethnically diverse population: focus on Hispanics 
Annals of epidemiology  2012;23(1):19-24.
To understand if Hispanics report health differently than other racial/ethnic groups after controlling for demographics and risk factors for poor health.
The sample (n=5,502) included 3,201 women, 1,767 black, 1,859 white and 1,876 Hispanic subjects from the Boston Area Community Health Survey, a population-based survey of English and Spanish-speaking residents of Boston, Massachusetts, United States, age 30–79 in 2002–05. Multiple logistic regression was used to examine the association between race/ethnicity (including interview language for Hispanics) and fair/poor self-reported health (F/P SRH) adjusting for gender, age, socioeconomic status (SES), depression, nativity, and comorbidities.
Compared to whites, Hispanics interviewed in Spanish were seven times as likely to report F/P SRH (Odds Ratio = 7.7, 95% confidence interval 4.9, 12.2) after adjusting for potential confounders and Hispanics interviewed in English were twice as likely. In analyses stratified by depression and nativity, we observed stronger associations with Hispanic ethnicity in immigrants and non-depressed individuals interviewed in Spanish.
Increased odds of F/P SRH persisted in the Hispanic group even when accounting for interview language and controlling for SES, age, depression, and nativity, with language of interview mitigating the association. These findings have methodologic implications for epidemiologists using SRH across diverse populations.
PMCID: PMC3519959  PMID: 23149066
Hispanic Americans; self-reported; health status; comorbidity
2.  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
3.  Determinants of Self-Rated Health in a Representative Sample of a Rural Population: A Cross-Sectional Study in Greece 
Self-rated health (SRH) is a health measure related to future health, mortality, healthcare services utilization and quality of life. Various sociodemographic, health and lifestyle determinants of SRH have been identified in different populations. The aim of this study is to extend SRH literature in the Greek population. This is a cross-sectional study conducted in rural communities between 2001 and 2003. Interviews eliciting basic demographic, health-related and lifestyle information (smoking, physical activity, diet, quality of sleep and religiosity) were conducted. The sample consisted of 1,519 participants, representative of the rural population of Tripoli. Multinomial regression analysis was conducted to identify putative SRH determinants. Among the 1,519 participants, 489 (32.2%), 790 (52%) and 237 (15.6%) rated their health as “very good”, “good” and “poor” respectively. Female gender, older age, lower level of education and impaired health were all associated with worse SRH, accounting for 16.6% of SRH variance. Regular exercise, healthier diet, better sleep quality and better adherence to religious habits were related with better health ratings, after adjusting for sociodemographic and health-related factors. BMI and smoking did not reach significance while exercise and physical activity exhibited significant correlations but not consistently across SRH categories. Our results support previous findings indicating that people following a more proactive lifestyle pattern tend to rate their health better. The role of stress-related neuroendocrinologic mechanisms on SRH and health in general is also discussed.
PMCID: PMC3367289  PMID: 22690175
self-rated health; determinants; lifestyle; sleep; religiosity; cross-sectional
4.  Question context and priming meaning of health: effect on differences in self-rated health between Hispanics and non-Hispanic Whites 
American journal of public health  2013;104(1):179-185.
Despite little empirical evidence, the current data collection practice recommends placing self-rated health (SRH) before specific health-related questions (hence, without a health context) to remove potential context effects. This paper examined the implications of this design on measurement comparability between Hispanics and non-Hispanics.
This study used two methodologically comparable surveys conducted in English and Spanish that asked SRH in different contexts: before and after specific health questions. Focusing on the elderly, we compared the influence of question contexts on SRH between Hispanics and non-Hispanics and between Spanish and English speakers.
Results showed that the question context influenced SRH reports of Spanish speakers (and Hispanics) drastically but not of English speakers (and non-Hispanics). Specifically, on SRH within a health context, Hispanics reported more positive health, decreasing the gap with non-Hispanic Whites by two thirds, and the measurement utility of SRH was improved through more consistent mortality prediction across ethnic/linguistic groups.
Contrary to the current recommendation, asking SRH within a health context enhanced measurement utility. Studies using SRH may result in erroneous conclusions when not considering its question context.
PMCID: PMC3910022  PMID: 23678900
5.  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
6.  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
7.  Self-rated health and ethnicity: focus on indigenous populations 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.18538.
Self-rated health (SRH) is a commonly used measure in surveys to assess general health status or health-related quality of life. Differences have been detected in how different ethnic groups and nationalities interpret the SRH measure and assess their health. This review summarizes the research conducted on SRH within and between ethnic groups, with a focus on indigenous groups.
Study design and methods
A search of published academic literature on SRH and ethnicity, including a comprehensive review of all relevant indigenous research, was conducted using PubMed and summarized.
A wide variety of research on SRH within ethnic groups has been undertaken. SRH typically serves as an outcome measure. Minority respondents generally rated their health worse than the dominant population. Numerous culturally-specific determinants of SRH have been identified. Cross-national and cross-ethnicity comparisons of the associations of SRH have been conducted to assess the validity of SRH. While SRH is a valid measure within a variety of ethnicities, differences in how SRH is assessed by ethnicities have been detected. Research in indigenous groups remains generally under-represented in the SRH literature.
These results suggest that different ethnic groups and nationalities vary in SRH evaluations, interpretation of the SRH measure, and referents employed in rating health. To effectively assess and redress health disparities and establish culturally-relevant and effective health interventions, a greater understanding of SRH is required, particularly among indigenous groups, in which little research has been conducted.
PMCID: PMC3417472  PMID: 22663937
self-rated health (SRH); ethnicity; indigenous health; health measures; surveys
8.  Language and Regional Differences in Evaluations of Medicare Managed Care by Hispanics 
Health Services Research  2008;43(2):552-568.
This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS®) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country.
Data Sources
CAHPS 3.0 Medicare managed care survey data collected in 2002.
Study Design
The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health.
Data Collection/Extraction Methods
The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish.
Principal Findings
Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care.
Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.
PMCID: PMC2442381  PMID: 18370967
CAHPS; patient experiences; Medicare managed care; Hispanics; language; ethnic disparities; geographic variations
9.  Self ratings of health predict functional outcome and recurrence free survival after stroke 
Study objective: To measure stroke victims' self rated health (SRH) status and SRH transition, and to compare how the two are prospectively associated with disability and recurrence free survival.
Design: Prospective case registry study with face to face follow up interviews at three months, one, two, and three years. Ascertained were SRH status and SRH transition using single question assessments, Barthel Index (BI), Frenchay Activities Index (FAI), and Mini Mental State Examination (MMSE).
Setting: A multiethnic inner city population of 234 533.
Participants: Patients surviving the initial three months after a first in a lifetime stroke in 1995 to 1998.
Results: Of 690 stroke survivors 561 (81.3%) could complete the self report items. Answers to the item on SRH status did not vary significantly between the four follow up interviews. However, responses to the item on SRH transition changed significantly during follow up with three months ratings being more negative than all subsequent ratings. SRH transition, but not SRH status, showed a prospective association with long term outcome in multivariate analyses controlling for the BI, FAI, and MMSE. Compared with all other patients, patients reporting "Much worse health" at three months were more likely to be disabled ( = BI<20) at one year (OR 6.29, 95% CI 2.26 to 17.52) and their combined risk of stroke recurrence and death was increased over five years (HR 1.72, 95% CI 1.25 to 2.38).
Conclusions: Items on SRH should be used with caution in populations with high rates of disability and language problems, as many participants are unable to complete them. SRH transition may be a better predictor of disability and recurrence free survival after major medical events than SRH status.
PMCID: PMC1732360  PMID: 14652262
10.  Predictors of Self-rated Health Status Among Texas Residents 
Preventing Chronic Disease  2005;2(4):A12.
The purpose of this study was to investigate the predictors of self-rated health status for Texas adults using the current 2003 Behavioral Risk Factor Surveillance System data. Self-rated health is generally accepted as a valid measure of health status in population studies, and understanding its correlates may help public health professionals prioritize health-promotion and disease-prevention interventions.
The two research questions addressed by this study involved the predictors of self-rated health: 1) "Do demographic characteristics, health care coverage, leisure-time physical activity, and body mass index predict self-rated health status for Texas residents aged 18 to 64 years?" and 2) "Does choice of interview language (English vs Spanish) predict self-rated health status for Texas residents of Hispanic ethnicity aged 18 to 64 years?" Key analysis variables were identified, and descriptive statistics were used to describe the major variables and determine whether the number of respondents for each variable was sufficient for analysis. Multivariate regression analysis was used to assess the variables.
Multiple logistic regression analysis (controlling for diabetes and arthritis) of the self-rated health predictors indicated that older age, lack of health care coverage, lack of a college education, being Hispanic, having a lower income, obesity, and not exercising explained 19.4% of the variance of fair and poor self-rated health. The interview language (English or Spanish), age, sex, education, income, obesity, health insurance coverage, and physical activity (controlling for chronic illness) explained 22.8% of the variance in fair and poor self-rated health for Hispanic respondents.
The results of this study suggest that a college education, a lower body mass index, non-Hispanic ethnicity, and participation in physical activity are associated with good, very good, or excellent self-rated health status. The finding that the interview language significantly predicted fair and poor self-rated health substantiates previous research and emphasizes the importance of culturally sensitive approaches to health care services.
PMCID: PMC1435709  PMID: 16164816
11.  Health Characteristics and Health Behaviors of African American Adults According to Self-rated Health Status 
Ethnicity & disease  2014;24(1):97-103.
Although African Americans report poorer self-rated health (SRH) than Whites, few studies have explored what factors are associated with SRH in this population. Our study described the health characteristics and health behaviors of a sample of adult church members according to SRH status.
74 African Methodist Episcopal churches in South Carolina.
1077 church members (99% African American).
Main Outcome Measures
Self-reported physical activity, fruit and vegetable consumption, fat- and fiber-behaviors, perceived stress, and presence of chronic health conditions, objectively measured body mass index (BMI), waist circumference, and blood pressure. Health-related characteristics and health behaviors across SRH categories were calculated. Analysis of covariance examined relationships between SRH and the presence of chronic diseases, the total number of chronic diseases, health-related variables, and health behaviors.
The health characteristics and health behaviors of participants worsened with declining SRH. The percentage of participants with each individual chronic health condition increased, as did the total number of chronic health conditions, as SRH declined. A higher BMI, a greater waist circumference, and higher perceived stress were associated with poorer SRH. Participants with lower physical activity and poorer fat- and fiber-behaviors also had poorer SRH. Fruit and vegetable consumption was not associated with SRH.
A better understanding of what health-related variables and health behaviors contribute to SRH may inform future interventions, as researchers and practitioners can target and effectively change the most salient factors. Fortunately, a majority of the factors are modifiable and can be prevented or reversed with changes in lifestyle.
PMCID: PMC4230694  PMID: 24620455
Self-rated Health; Health Behaviors; Chronic Health Conditions; African Americans
12.  Self-rated health among Greenlandic Inuit and Norwegian Sami adolescents: associated risk and protective correlates 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.19793.
Self-rated health (SRH) and associated risk and protective correlates were investigated among two indigenous adolescent populations, Greenlandic Inuit and Norwegian Sami.
Cross-sectional data were collected from “Well-being among Youth in Greenland” (WBYG) and “The Norwegian Arctic Adolescent Health Study” (NAAHS), conducted during 2003–2005 and comprising 10th and 11th graders, 378 Inuit and 350 Sami.
SRH was assessed by one single item, using a 4-point and 5-point scale for NAAHS and WBYG, respectively. Logistic regressions were performed separately for each indigenous group using a dichotomous measure with “very good” (NAAHS) and “very good/good” (WBYG) as reference categories. We simultaneously controlled for various socio-demographics, risk correlates (drinking, smoking, violence and suicidal behaviour) and protective correlates (physical activity, well-being in school, number of close friends and adolescent–parent relationship).
A majority of both Inuit (62%) and Sami (89%) youth reported “good” or “very good” SRH. The proportion of “poor/fair/not so good” SRH was three times higher among Inuit than Sami (38% vs. 11%, p≤0.001). Significantly more Inuit females than males reported “poor/fair” SRH (44% vs. 29%, p≤0.05), while no gender differences occurred among Sami (12% vs. 9%, p≤0.08). In both indigenous groups, suicidal thoughts (risk) and physical activity (protective) were associated with poor and good SRH, respectively.
In accordance with other studies of indigenous adolescents, suicidal thoughts were strongly associated with poorer SRH among Sami and Inuit. The Inuit–Sami differences in SRH could partly be due to higher “risk” and lower “protective” correlates among Inuit than Sami. The positive impact of physical activity on SRH needs to be targeted in future intervention programs.
PMCID: PMC3567202  PMID: 23396865
adolescents; Arctic; indigenous; Inuit; protective factors; risk factors; Sami; self-rated health (SRH); suicidal behaviours
13.  The association of neighbourhood and individual social capital with consistent self-rated health: a longitudinal study in Brazilian pregnant and postpartum women 
Social conditions, social relationships and neighbourhood environment, the components of social capital, are important determinants of health. The objective of this study was to investigate the association of neighbourhood and individual social capital with consistent self-rated health in women between the first trimester of pregnancy and six months postpartum.
A multilevel cohort study in 34 neighbourhoods was performed on 685 Brazilian women recruited at antenatal units in two cities in the State of Rio de Janeiro, Brazil. Self-rated health (SRH) was assessed in the 1st trimester of pregnancy (baseline) and six months after childbirth (follow-up). The participants were divided into two groups: 1. Good SRH – good SRH at baseline and follow-up, and, 2. Poor SRH – poor SRH at baseline and follow-up. Exploratory variables collected at baseline included neighbourhood social capital (neighbourhood-level variable), individual social capital (social support and social networks), demographic and socioeconomic characteristics, health-related behaviours and self-reported diseases. A hierarchical binomial multilevel analysis was performed to test the association between neighbourhood and individual social capital and SRH, adjusted for covariates.
The Good SRH group reported higher scores of social support and social networks than the Poor SRH group. Although low neighbourhood social capital was associated with poor SRH in crude analysis, the association was not significant when individual socio-demographic variables were included in the model. In the final model, women reporting poor SRH both at baseline and follow-up had lower levels of social support (positive social interaction) [OR 0.82 (95% CI: 0.73-0.90)] and a lower likelihood of friendship social networks [OR 0.61 (95% CI: 0.37-0.99)] than the Good SRH group. The characteristics that remained associated with poor SRH were low level of schooling, Black and Brown ethnicity, more children, urinary infection and water plumbing outside the house.
Low individual social capital during pregnancy, considered here as social support and social network, was independently associated with poor SRH in women whereas neighbourhood social capital did not affect women’s SRH during pregnancy and the months thereafter. From pregnancy and up to six months postpartum, the effect of individual social capital explained better the consistency of SRH over time than neighbourhood social capital.
PMCID: PMC3556498  PMID: 23324161
Women’s health; Self-rated health; Dental public health; Social capital; Social network; Social support; multilevel analysis
14.  Television viewing by young Latino children: Evidence of heterogeneity 
To determine if hours of daily television viewed by varying age groups of young children with Latina mothers differs by maternal language preference (English/Spanish) and to compare these differences to young children with non-Latina white mothers.
Cross-sectional analysis of data collected in 2000 from the National Survey of Early Childhood Health.
Nationally representative sample.
1,347 mothers of children 4-35 months.
Main Exposure
Subgroups of self-reported maternal race/ethnicity (non-Latina white (white), Latina) and within Latinas, stratification by maternal language preference (English/Spanish).
Outcome Measure
Hours of daily television viewed by the child.
Bivariate analyses showed children of English- versus Spanish-speaking Latinas watch more daily television (1.88 versus 1.31 hours,p<0.01). Multivariable regression analyses stratified by age revealed differences by age group. Among 4-11 month olds, children of English- and Spanish-speaking Latinas watch similar amounts of television. However, among children 12-23 and 24-35 months, children of English-speaking Latinas watched more television than children of Spanish-speaking Latinas (IRR=1.61,CI=1.17-2.22; IRR=1.66,CI=1.10-2.51, respectively). Compared to children of white mothers, children of both Latina subgroups watched similar amounts among the 4-11 month olds. However, among 12-23 month olds, children of English-speaking Latinas watched more compared to children of white mothers (IRR=1.57,CI=1.18-2.11). Among 24-35 month olds, children of English-speaking Latinas watched similar amounts compared to children of white mothers, but children of Spanish-speaking Latinas watched less (IRR=0.69,CI=0.50-0.95).
Television viewing amounts among young children with Latina mothers vary by child age and maternal language preference supporting the need to explore sociocultural factors that influence viewing in Latino children.
PMCID: PMC2828343  PMID: 20124147
15.  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
16.  Measuring Disparities: Bias in the SF-36v2 among Spanish-speaking Medical Patients 
Medical care  2011;49(5):480-488.
Many national surveys have found substantial differences in self-reported overall health (SROH) between Spanish-speaking Hispanics and other racial/ethnic groups. However, because cultural and language differences may create measurement bias, it is unclear whether observed differences in SROH reflect true differences in health.
This study uses a cross-sectional survey to investigate psychometric properties of the SF-36v2 for subjects across four racial/ethnic and language groups. Multi-group latent variable modeling was used to test increasingly stringent criteria for measurement equivalence.
Our sample (N = 1281) included 383 non-Hispanic whites, 368 non-Hispanic blacks, 206 Hispanics interviewed in English and 324 Hispanics interviewed in Spanish recruited from outpatient medical clinics in two large urban areas.
We found weak factorial invariance across the four groups. However, there was no strong factorial invariance. The overall fit of the model was substantially worse (change in CFI > .02, RMSEA change > .003) after requiring equal intercepts across all groups. Further comparisons established that the equality constraints on the intercepts for Spanish-speaking Hispanics were responsible for the decrement to model fit.
Observed differences between SF-36v2 scores for Spanish speaking Hispanics are systematically biased relative to the other three groups. The lack of strong invariance suggests the need for caution when comparing SF-36v2 mean scores of Spanish-speaking Hispanics with those of other groups. However, measurement equivalence testing for this study supports correlational or multivariate latent variable analyses of SF-36v2 responses across all four subgroups, since these analyses require only weak factorial invariance.
PMCID: PMC3078179  PMID: 21430580
disparities; measurement self-reported health; race/ethnicity; SF-36v2
17.  Self-ratings of Health and Change in Walking Speed Over 2 Years: Results From the Caregiver-Study of Osteoporotic Fractures 
American Journal of Epidemiology  2011;173(8):882-889.
Although poorer self-rated health (SRH) is associated with increased mortality, less is known about its impact on functioning. This study evaluated whether poorer SRH was associated with decline in walking speed and whether caregiving, often considered an indicator of chronic stress, modified this relation. The sample included 891 older US women from the Caregiver-Study of Osteoporotic Fractures. SRH was assessed at the baseline Caregiver-Study of Osteoporotic Fractures interview, conducted in 1999–2001, and was categorized as fair/poor or excellent/good. Rapid walking speed over 2, 3, or 6 m was measured at baseline and 2 annual follow-up interviews. Respondents with fair/poor SRH walked significantly slower at baseline than those with excellent/good health (mean = 0.8 (standard deviation, 0.3) vs. 1.0 (standard deviation, 0.3) m/second, P < 0.001). In adjusted linear mixed models of percentage change in walking speed, respondents with fair/poor SRH experienced a greater decline in walking speed than those with excellent/good SRH (−5.66% vs. −0.60%, P = 0.01). Caregivers with fair/poor SRH declined more than noncaregivers (−9.26% vs. −4.09%). High-intensity caregivers had the largest decline (−12.88%), whereas low-intensity caregivers in excellent/good SRH had no decline (2.61%). In summary, poorer SRH was associated with decline in walking speed in older women, and the stress of caregiving may have exacerbated its impact.
PMCID: PMC3105256  PMID: 21354990
aged; caregivers; gait; health; self report; walking
18.  Recruiting Ethnically Diverse General Internal Medicine Patients for a Telephone Survey on Physician-Patient Communication 
Limited evidence exists on the effectiveness of recruitment methods among diverse populations.
Describe response rates by recruitment stage, ethnic-language group, and type of initial contact letter (for African-American and Latino patients).
Tracking of response status by recruitment stage and ethnic-language group and a randomized trial of ethnically tailored initial letters nested within a cross-sectional telephone survey on physician-patient communication.
Adult general medicine patients with ≥1 visit during the preceding year, stratified by 4 categories: African-American (N= 1,400), English-speaking Latino (N= 894), Spanish-speaking Latino (N= 965), and non-Latino white (N= 1,400).
Ethnically tailored initial letters referred to shortages of African-American (or Latino) physicians and the need to learn about the experiences of African-American (or Latino) patients communicating with physicians. Of 2,482 patients contacted, eligible, and able to participate (identified eligibles), 69.9% completed the survey. Thirty-nine percent of the sampling frame was unable to be contacted, with losses higher among non-Latino whites (46.5%) and African Americans (44.2%) than among English-speaking (32.3%) and Spanish-speaking Latinos (25.1%). For identified eligibles, response rates were highest among Spanish-speaking Latinos (75.2%), lowest for non-Latino whites (66.4%), and intermediate for African Americans (69.7%) and English-speaking Latinos (68.1%). There were no differences in overall response rates between patients receiving ethnically tailored letters (72.2%) and those receiving general letters (70.0%).
Household contact and individual response rates differed by ethnic-language group, highlighting the importance of tracking losses by stage and subpopulation. Careful attention to recruitment yielded acceptable response rates among all groups.
PMCID: PMC1490122  PMID: 15963168
recruitment; telephone survey; African Americans; Latinos; physician-patient communication
19.  Self-rated health in Pakistan: results of a national health survey 
BMC Public Health  2005;5:51.
Self-rated health (SRH) is a robust predictor of mortality. In UK, migrants of South Asian descent, compared to native Caucasian populations, have substantially poorer SRH. Despite its validation among migrant South Asian populations and its popularity in developed countries as a useful public health tool, the SRH scale has not been used at a population level in countries in South Asia. We determined the prevalence of and risk factors for poor/fair SRH among individuals aged ≥15 years in Pakistan (n = 9442).
The National Health Survey of Pakistan was a cross-sectional population-based survey, conducted between 1990 and 1994, of 18 135 individuals aged 6 months and above; 9442 of them were aged ≥15 years. Our main outcome was SRH which was assessed using the question: "Would you say your health in general is excellent, very good, good, fair, or poor?" SRH was dichotomized into poor/fair, and good (excellent, very good, or good).
Overall 65.1% respondents – 51.3 % men vs. 77.2 % women – rated their health as poor/fair. We found a significant interaction between sex and age (p < 0.0001). The interaction was due to the gender differences only in the ages 15–19 years, whereas poor/fair SRH at all older ages was more prevalent among women and increased at the same rate as it did among men. We also found province of dwelling, low or middle SES, literacy, rural dwelling and current tobacco use to be independently associated with poor/fair SRH.
This is the first study reporting on poor/fair SRH at a population-level in a South Asian country. The prevalence of poor/fair health in Pakistan, especially amongst women, is one of the worst ever reported, warranting immediate attention. Further research is needed to explain why women in Pakistan have, at all ages, poorer SRH than men.
PMCID: PMC1164420  PMID: 15943882
20.  What about healthy participants? The improvement and deterioration of self-reported health at a 10-year follow-up of the Västerbotten Intervention Programme 
Global Health Action  2011;4:10.3402/gha.v4i0.5435.
The Västerbotten Intervention Programme (VIP) addresses cardiovascular disease and diabetes in the middle-aged population of Västerbotten County, Sweden. Self-reported health (SRH) is one of the risk factors for both conditions. The aim of this study was to analyse the development patterns of SRH among the VIP participants.
Cross-sectional data from 1990 to 2007 were used to analyse the prevalence of poor SRH among 101,396 VIP participants aged 40–60 years. Panel data were used to study the change in SRH among 25,695 persons aged 30–60 years, who participated in the VIP twice within a 10-year interval.
Prevalence of poor SRH fluctuated between 1990 and 2007 in Västerbotten County. There was a temporary decline around 2000, with SRH continuously improving thereafter. The majority of panel participants remained in good SRH; over half of those with poor or fair SRH at baseline reported better SRH at follow-up. SRH declined in 19% of the panel participants, mostly among those who had good SRH at the baseline. The decline was common among both women and men, in all educational, age and marital status groups.
The SRH improvement among those with poor and fair SRH at baseline suggests that VIP has been successful in addressing its target population. However, the deterioration of SRH among 21% of the individuals with good SRH at baseline is of concern. From a public health perspective, it is important for health interventions to address not only the risk group but also those with a healthy profile to prevent the negative development among the seemingly healthy participants.
PMCID: PMC3179265  PMID: 21949500
self-reported health; intervention; Västerbotten; Sweden
21.  Longitudinal Association Between Self-rated Health and Timed Gait Among Older Persons 
We evaluated the longitudinal association between self-rated health (SRH) and timed gait, an indicator of lower extremity dysfunction, in a community-based sample of older persons.
Participants (N = 754) were evaluated at 18-month intervals for 72 months. SRH was categorized as Excellent/Very Good/Good and Fair/Poor. Participants were asked to walk a 10-foot course “as fast as it feels safe and comfortable,” turn around, and walk back, with timed gait defined as normal (≤10 s) or slow (>10 s). Generalized multinomial logit models, adjusted for demographic features, biomedical and psychosocial factors, and activities of daily living, evaluated the association between SRH and the likelihood of 6 possible transitions (from normal or slow timed gait to normal timed gait, slow timed gait, or death) over time. We also ran a repeated measures linear mixed model with change in timed gait as the outcome.
Compared with participants reporting Excellent/Very Good/Good SRH, those reporting Fair/Poor SRH were more likely to transition from normal to slow timed gait or to death. SRH was not associated with transitions from slow timed gait to normal timed gait or to death. In addition, time to complete the gait task increased (i.e., slowed) over time among participants reporting Fair/Poor SRH compared with those reporting Excellent/Very Good/Good SRH.
Among older persons, SRH is associated with the development of lower extremity dysfunction but not with recovery from lower extremity dysfunction. This relationship may indicate an intermediate step in the pathway from SRH to mortality.
PMCID: PMC2954321  PMID: 20028951
Gait; Longitudinal study; Objective measures; Older people; Self-rated health
22.  Estimated effects of potential interventions to prevent declines in self-rated health among breast cancer survivors 
Annals of Epidemiology  2012;22(2):79-86.
To estimate the effect of hypothetical changes in modifiable predictors on the incidence of fair-poor self-rated health (SRH) in breast cancer survivors.
In 2007-2008, we interviewed 832 breast cancer survivors 1 year after diagnosis (baseline) and 1 year later. First, multivariable logistic regression models estimated the association between the predictors (sociodemographic factors, access to medical care, comorbid conditions, psychosocial factors, perceived neighborhood conditions, cancer-related behaviors, clinical factors) and SRH. Second, we estimated the probabilities of fair-poor SRH for values of the predictors for each breast cancer survivor. Third, we estimated the population-wide effect of potential changes in modifiable predictors on the incidence of fair-poor SRH.
7.6% of participants (92.4% white; mean age: 58.0 years) whose SRH was rated good-excellent at baseline reported fair-poor SRH one year later. The largest potential reduction in incidence of fair-poor SRH could be obtained by eliminating surgical side effects (27.8% reduction) and comorbidity (21.8% reduction) and by engaging in any physical activity (19.6% reduction).
A significant portion of the decline in SRH can be avoided by reducing surgical side effects, preventing comorbidity and improving physical activity using evidence-based strategies.
PMCID: PMC3255081  PMID: 22226030
Breast Cancer; Intervention; Disability
23.  Do Physicians with Self-Reported Non-English Fluency Practice in Linguistically Disadvantaged Communities? 
Language concordance between physicians and patients may reduce barriers to care faced by patients with limited English proficiency (LEP). It is unclear whether physicians with fluency in non-English languages practice in areas with high concentrations of people with LEP.
To investigate whether physician non-English language fluency is associated with practicing in areas with high concentrations of people with LEP.
Cross-sectional cohort study.
A total of 61,138 practicing physicians no longer in training who participated in the California Medical Board Physician Licensure Survey from 2001–2007.
Self-reported language fluency in Spanish and Asian languages. Physician practice ZIP code corresponding to: (1) high concentration of people with LEP and (2) high concentration of linguistically isolated households.
Practice location ZIP code was geocoded with geographic medical service study designations. We examined the unadjusted relationships between physician self-reported fluency in Spanish and selected Asian languages and practice location, stratified by race-ethnicity. We used staged logistic multiple variable regression models to isolate the effect of self-reported language fluency on practice location controlling for age, gender, race-ethnicity, medical specialty, and international medical graduate status.
Physicians with self-reported fluency in Spanish or an Asian language were more likely to practice in linguistically designated areas in these respective languages compared to those without fluency. Physician fluency in an Asian language [adjusted odds ratio (AOR) = 1.77; 95% confidence intervals (CI): 1.63–1.92] was independently associated with practicing in areas with a high number of LEP Asian speakers. A similar pattern was found for Spanish language fluency (AOR = 1.77; 95% CI: 1.43–1.82) and areas with high numbers of LEP Spanish-speakers. Latino and Asian race-ethnicity had the strongest effect on corresponding practice location, and this association was attenuated by language fluency.
Physicians who are fluent in Spanish or an Asian language are more likely to practice in geographic areas where their potential patients speak the corresponding language.
PMCID: PMC3077490  PMID: 21120633
workforce; language; Hispanic American; Asian American
24.  Inequalities in self-rated health among 45+ year-olds in Almaty, Kazakhstan: a cross-sectional study 
BMC Public Health  2013;13:654.
Self-rated health (SRH) has been widely studied to assess health inequalities in both developed and developing countries. However, no studies have been performed in Central Asia. The aim of the study was to assess gender-, ethnic-, and social inequalities in SRH in Almaty, Kazakhstan.
Altogether, 1500 randomly selected adults aged 45 years or older were invited to participate in a cross-sectional study and 1199 agreed (response rate 80%). SRH was classified as poor, satisfactory, good and excellent. Multinomial logistic regression was applied to study associations between SRH and socio-demographic characteristics. Crude and adjusted odds ratios (OR) for poor vs. good and for satisfactory vs. good health were calculated with 95% confidence intervals (CI).
Altogether, poor, satisfactory, good and excellent health was reported by 11.8%, 53.7%, 31.0% and 3.2% of the responders, respectively. Clear gradients in SRH were observed by age, education and self-reported material deprivation in both crude and adjusted analyses. Women were more likely to report poor (OR = 1.9, 95% CI: 1.2-3.1) or satisfactory (OR = 1.6, 95% CI: 1.2-2.1) than good health. Ethnic Russians and unmarried participants had greater odds for poor vs. good health (OR = 2.3, 95% CI: 1.5-3.7 and OR = 4.0, 95% CI: 2.7-6.1, respectively) and for satisfactory vs. good health (OR = 1.4, 95% CI: 1.1-1.9 and OR = 1.9, 95% CI: 1.4-2.5, respectively) in crude analysis, but the estimates were reduced to non-significant levels after adjustment. Unemployed and pensioners were less likely to report good health than white-collar workers while no difference in SRH was observed between white- and blue-collar workers.
Considerable levels of inequalities in SRH by age, gender, education and particularly self-reported material deprivation, but not by ethnicity or marital status were found in Almaty, Kazakhstan. Further research is warranted to identify the factors behind the observed associations in Kazakhstan.
PMCID: PMC3717110  PMID: 23855346
Central Asia; Kazakhstan; Self-rated health; Determinants; Socio-demographic
25.  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

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