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1.  Nuevo Amanecer: Results of a Randomized Controlled Trial of a Community-Based, Peer-Delivered Stress Management Intervention to Improve Quality of Life in Latinas With Breast Cancer 
American journal of public health  2015;105(0 3):e55-e63.
We evaluated a community-based, translational stress management program to improve health-related quality of life in Spanish-speaking Latinas with breast cancer.
We adapted a cognitive–behavioral stress management program integrating evidence-based and community best practices to address the needs of Latinas with breast cancer. Spanish-speaking Latinas with breast cancer were randomly assigned to an intervention or usual-care control group. Trained peers delivered the 8-week intervention between February 2011 and February 2014. Primary outcomes were breast cancer–specific quality of life and distress, and general symptoms of distress.
Of 151 participants, 95% were retained at 6 months (between May 2011 and May 2014). Improvements in quality of life from baseline to 6 months were greater for the intervention than the control group on physical well-being, emotional well-being, breast cancer concerns, and overall quality of life. Decreases from baseline to 6 months were greater for the intervention group on depression and somatization.
Results suggest that translation of evidence-based programs can reduce psychosocial health disparities in Latinas with breast cancer. Integration of this program into community-based organizations enhances its dissemination potential.
PMCID: PMC4455521  PMID: 25905829
2.  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
3.  A Randomized Trial to Assess the Effect of a Research Informational Pamphlet on Telephone Survey Completion Rates among Older Latinos 
Contemporary Clinical Trials  2012;33(4):624-627.
Purpose of the study
To assess the effects of receiving a research informational pamphlet produced by the federal Office for Human Research Protections on telephone survey participation rates of older Latinos, and illustrate the feasibility of nesting recruitment studies within other funded studies when stand alone funding for recruitment studies is limited.
Design and Methods
Latino patients aged ≥ 50 with ≥1 visit during the preceding year (N=1,314) were sampled from three community clinics and a multi-specialty medical group. Patients were randomly assigned to receive or not receive a pamphlet that contained information on research participation in the initial mailing for the telephone survey study. Survey participation rates were compared between the pamphlet and no pamphlet groups.
In a multivariate model, women (OR=1.4; 95% CI 1.1, 1.8), and those with public insurance (vs. no insurance; OR=1.7; 95% CI 1.1, 2.5) were more likely to participate, while those age 65+ (vs. age 50–54; OR=0.6; 95% CI 0.4, 0.8) were less likely to participate; there was no significant difference by pamphlet group (OR=0.8; 95% CI 0.7, 1.1). Nesting of the randomized trial of the recruitment pamphlet within the funded study required minimal additional resources.
Recruitment methods that are more intensive than a pamphlet may be needed to enhance survey participation rates among older Latinos. Nesting recruitment trials within funded studies is a promising and efficient approach for testing recruitment strategies.
PMCID: PMC3361585  PMID: 22449837
Latinos; Hispanics; randomized trial; response rate; research participation
4.  Methods for Translating Evidence-Based Behavioral Interventions for Health-Disparity Communities 
Populations composed of racial/ethnic minorities, disabled persons, and people with low socioeconomic status have worse health than their counterparts. Implementing evidence-based behavioral interventions (EBIs) to prevent and manage chronic disease and disability in community settings could help ameliorate disparities. Although numerous models of implementation processes are available, they are broad in scope, few offer specific methodological guidance, and few address the special issues in reaching vulnerable populations. Drawing from 2 existing models, we describe 7 methodological phases in the process of translating and implementing EBIs in communities to reach these vulnerable groups: establish infrastructure for translation partnership, identify multiple inputs (information gathering), review and distill information (synthesis), adapt and integrate program components (translation), build general and specific capacity (support system), implement intervention (delivery system), and develop appropriate designs and measures (evaluation). For each phase, we describe specific methodological steps and resources and provide examples from research on racial/ethnic minorities, disabled persons, and those with low socioeconomic status. Our methods focus on how to incorporate adaptations so that programs fit new community contexts, meet the needs of individuals in health-disparity populations, capitalize on scientific evidence, and use and build community assets and resources. A key tenet of our approach is to integrate EBIs with community best practices to the extent possible while building local capacity. We discuss tradeoffs between maintaining fidelity to the EBIs while maximizing fit to the new context. These methods could advance our ability to implement potentially effective interventions to reduce health disparities.
PMCID: PMC3839588  PMID: 24262025
5.  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
6.  Maternal Acculturation and the Prenatal Care Experience 
Journal of Women's Health  2014;23(8):688-706.
Background: Acculturation may influence women's perceptions of health care experiences and may explain the epidemiologic paradox, whereby foreign-born women have lower rates of adverse birth outcomes than United States (US)-born women. We evaluated the relationship between maternal acculturation and specific dimensions of prenatal interpersonal processes of care (IPC) in ethnically diverse women.
Methods: Cross-sectional analysis of 1243 multiethnic, postpartum women who delivered at Kaiser Permanente Medical Center in Walnut Creek or San Francisco General Hospital. Women retrospectively reported on their experiences in seven domains of IPC during their pregnancy pertaining to communication, decision making, and interpersonal style. The primary independent variables were four measures of maternal acculturation: birthplace, English language proficiency, the number of years residing in the US, and age at immigration to the US. Generalized linear models, stratified by infant outcome, measured the association between each maternal acculturation measure and specific IPC domains while adjusting for type of health insurance, demographic, and reproductive factors.
Results: Approximately 60% of the sample was foreign-born, 36% reported low English proficiency, 43% had resided in the US <10 years, and 35% were age 20 years or older when they immigrated to the US. Over 64% of the women reported having public insurance during pregnancy. In adjusted analyses among women who delivered term and normal birth weight infants, less acculturated women and women with non-private health insurance were more likely to have higher mean IPC scores when compared to more acculturated or US-born women and women with private health insurance, respectively.
Conclusion: In a large and ethnically diverse sample of childbearing women in Northern California, less acculturated pregnant women reported better prenatal care experiences than more acculturated and US-born women, another dimension of the “epidemiologic paradox.” However, the relationship between acculturation and IPC, as reported during the postpartum period, differed according to infant outcomes.
PMCID: PMC4129971  PMID: 24979178
7.  Physical Activity Outcomes of CHAMPS II: A Physical Activity Promotion Program for Older Adults 
Despite well-known benefits of physical activity for older adults, about two thirds are underactive. Community-based programs are needed to facilitate increased physical activity. We examine the effectiveness of CHAMPS II, an inclusive, choice-based physical activity promotion program to increase lifetime physical activity levels of seniors. CHAMPS guided participants to choose activities that took into account their health, preferences, and abilities. It offered information on ways for them to exercise safely, motivate themselves, overcome barriers, and develop a balanced exercise regimen.
A 1-year randomized controlled trial was conducted with physically underactive seniors in a multispecialty group practice. Changes in self-reported physical activity by group were evaluated using ANCOVA, controlling for age and sex.
Of 173 randomized subjects, 164 (95%) completed the trial. Subjects were aged 65 to 90 years (M = 74, SD = 6); 66% were female. The intervention group increased estimated caloric expenditure by 487 calories/week in moderate (or greater) intensity activities (MET ≥3.0; p < .001) and by 687 calories/week in physical activities of any intensity (p = .001). Control group changes were negligible. Between-group analyses found that the changes were significantly different in both measures (p values < .05). Overweight persons especially benefited from this program. The program was as effective for women, older adults (75+), and those who did not set aside time to exercise at baseline.
The program led to meaningful physical activity increases. Individually tailored programs to encourage lifestyle changes in seniors may be effective and applicable to health care and community settings.
PMCID: PMC1780022  PMID: 11487597
8.  Randomized Controlled Trial of Nuevo Amanecer: A Peer-delivered Stress Management Intervention for Spanish-speaking Latinas with Breast Cancer 
Clinical trials (London, England)  2014;11(2):230-238.
Latinas with breast cancer suffer symptom and psychosocial health disparities. Effective interventions have not been developed for or tested in this population.
We describe community-based participatory research methods used to develop and implement the Nuevo Amanecer program, a culturally tailored, peer-delivered cognitive-behavioral stress management intervention for low-income Spanish-speaking Latinas with breast cancer, and unique considerations in implementing a randomized controlled trial to test the program in community settings.
We applied an implementation science framework to delineate the methodological phases used to develop and implement the Nuevo Amanecer program and trial, emphasizing community engagement processes.
In phase 1, we established project infrastructure: academic and community Co-Principal Investigators, community partners, community advisory board, steering committee, and funding. In phase 2, we identified three program inputs: formative research, a community best practices model, and an evidence-based intervention tested in non-Latinas. In phase 3, we created the new program by integrating and adapting intervention components from the three sources, making adaptations to accommodate low-literacy, Spanish language, cultural factors, community context, and population needs. In phase 4, we built community capacity for the program and trial by training field staff (recruiters and interventionists embedded in community sites), compensating field staff, and creating a system for identifying potential participants. In phase 5, we implemented and monitored the program and trial. Engaging community partners in all phases has resulted in a new, culturally tailored program that is suitable for newly diagnosed Latinas with breast cancer and a trial that is acceptable and supported by community and clinical partners.
Lessons Learned
Engagement of community-based organizations and cancer survivors as research partners and hiring recruiters and interventionists from the community were critical to successful implementation in community settings. Having culturally and linguistically competent research staff with excellent interpersonal skills facilitated implementation. Facilitating and maintaining excellent communication among community partners was imperative to troubleshoot implementation issues. Randomization was challenging due to community concerns about assigning women to a control group. Patient privacy regulations and the need for extensive outreach to establish relationships between community partners and clinical sites hampered initial recruitment.
These were resource-intensive processes to develop and implement the program that need to be compared to less intensive alternatives.
Engaging community members in design and implementation of community-based programs and trials enhances cultural appropriateness and congruence with the community context. If the randomized trial demonstrates that the intervention is effective, it will fill a gap in evidence-based programs to address ethnic disparities in quality of life among Spanish-speaking Latinas with breast cancer.
PMCID: PMC3972263  PMID: 24577971
Spanish-speaking Latinas; breast cancer; stress management; quality-of-life; randomized controlled trial protocol
Maternal & child nutrition  2012;9(3):425-430.
Exclusive breastfeeding provides optimal nutrition through 6 months. Recent research has shown that milk expression may affect breastfeeding duration. A woman’s experience with milk expression might mediate the effect of milk expression on breastfeeding duration. The objective of this study is to develop a measure to evaluate women’s experiences of expressing milk.
Based on available literature, we developed a brief measure of the Breast Milk Expression Experience (BMEE) assessing 3 dimensions: 1) social support for milk expression, 2) ease of learning how to express milk, and 3) personal experiences of milk expression. All items used 1–5 Likert scales, with higher scores indicating better experiences. We administered the items immediately after expression to 68 mothers who expressed milk postpartum. We evaluated this measure for reliability using Cronbach’s alpha.
Mothers completing the BMEE were 57% primiparous with 75% vaginal births. The BMEE demonstrated appropriate reliability with a Cronbach’s alpha of 0.703 for the summary index and 0.719–0.763 for social support, learning experience and personal experience subscales. The BMEE also indicated good predictive validity; of the 6 mothers who had a mean score <3 on the 11-item scale postpartum, 2 (33.3%) were expressing breast milk at 1 month, compared with 37 (80.4%) of the 46 mothers who had a mean score ≥3 on the 11-item scale postpartum (p=0.012).
The BMEE is a promising measure of milk expression experience in this population. Use of this measure may allow improved understanding of women’s experiences expressing milk.
PMCID: PMC3350756  PMID: 22236401
Breastfeeding; lactation; breast milk expression; Breastfeeding Duration; Breastfeeding Knowledge; Breastfeeding Support
10.  Patient-Physician Interaction and Quality of Life in Recently Diagnosed Breast Cancer Patients 
Few studies have explored how patient-physician interactions influence patients’ quality of life (QOL). In a prospective cohort study of 1,855 women diagnosed with invasive breast cancer in the Kaiser Permanente Northern California (KPNC) Medical Care Program from 2006 to 2011, we examined associations between patient-physician interactions during cancer treatment and QOL, overall and by racial/ethnic group.
Participants completed the Interpersonal Processes of Care (IPC) Survey at approximately eight months post-diagnosis to assess specific domains of the patient-physician interaction during the months after cancer diagnosis. Domains included: compassion, elicited concerns, explained results, decided together, lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff. The Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B) was completed concurrently to measure QOL. Linear regression models examined the association of IPC with QOL, first adjusting for patient covariates including age, race, clinical factors, and psychosocial measures and then for physician characteristics such as age, sex, race/ethnicity, and specialty.
For all participants (n=1,855), IPC scores suggesting greater lack of clarity, discrimination due to race/ethnicity, and disrespectful office staff in patient-physician interactions were associated with lower QOL (p<0.01). IPC scores suggesting physicians demonstrating compassion, eliciting concerns, or explaining results were associated with higher QOL (p<0.01). Among Whites (n=1,306), only the associations with higher QOL remained. African Americans (n=110) who reported higher scores on physician compassion and elicited concerns had higher QOL, whereas higher scores for disrespectful office staff had lower QOL. No associations were observed among Asians (n=201) and Hispanics (n=186). After further adjustment for physician factors, the associations among Whites remained whereas those among African Americans disappeared.
In the breast cancer treatment setting, characteristics of the patient-physician interaction as perceived by the patient are associated with QOL, yet were not specific to patient race/ethnicity.
PMCID: PMC3707405  PMID: 23715629
Quality of life; patient-physician interaction; interpersonal processes of care; breast cancer; survival
12.  Asian Indian Views on Diet and Health in the United States 
Family & community health  2013;36(4):311-323.
This study describes Asian Indian immigrant perspectives surrounding dietary beliefs and practices to identify intervention targets for diabetes and heart disease prevention. Participants were asked about conceptualizations of relationships between culture, food, and health during 4 focus groups (n = 38). Findings reveal influences of beliefs from respondents’ native India, preservation of cultural practices within the US social structure, conflicts with subsequent generations, and reinterpretation of health-related knowledge through a lens, hybridizing both “native” and “host” contexts. Galvanization of ethnically valued beliefs incorporating family and community structures is needed for multipronged approaches to reduce disproportionate burdens of disease among this understudied minority community.
PMCID: PMC3987985  PMID: 23986072
Asian Indian; chronic disease; cultural contexts; disparities; qualitative inquiry
13.  Description of an Academic-Community Partnership Lifestyle Program for Lower-Income, Minority Adults at Risk for Diabetes 
The Diabetes educator  2010;36(4):640-650.
Translating strategies and approaches from the successful clinically-based Diabetes Prevention Program's lifestyle intervention to community settings is a key next step. This article describes a lifestyle program developed in partnership by researchers at a major university and public health professionals at a local health department.
The Live Well, Be Well (LWBW) program was designed to meet the needs of lower-income, minority, and low-literacy adults at risk for diabetes. It was adapted from interventions with demonstrated efficacy and delivered in Spanish and English by health department staff. The program consisted of a 6-month active phase and a 6-month maintenance phase and was primarily telephone-based, with one in-person planning session and several group workshops. In-person and group sessions were held in convenient community-based settings. Counselors provided education and skills training to modify diet and increase physical activity. Self-selected and attainable goal-setting and action plans were emphasized to enhance self-efficacy. LWBW is the intervention component of a randomized trial with primary outcomes of fasting glucose, weight, and other clinical measures.
The program provides a unique translational model for implementing diabetes risk reduction programs for underserved populations. Individually-tailored and non-prescriptive, it utilized existing health department infrastructure, focused on telephone counseling, used culturally-appropriate, low-literacy materials, and was delivered in local, community-based facilities.
PMCID: PMC3771540  PMID: 20576836
Translational research; lifestyle intervention; minority populations; academic-community partnership
14.  A Framework for Understanding Modifications to Measures for Diverse Populations 
Journal of aging and health  2012;24(6):992-1017.
Research on health disparities and determinants of health disparities among ethnic minorities and vulnerable older populations necessitates use of self-report measures. Most established instruments were developed on mainstream populations and may need adaptation for research with diverse populations. Although information is increasingly available on various problems using these measures in diverse groups, there is little guidance on how to modify the measures. We provide a framework of issues to consider when modifying measures for diverse populations.
We describe reasons for considering modifications, the types of information that can be used as a basis for making modifications, and the types of modifications researchers have made. We recommend testing modified measures to assure they are appropriate. Suggestions are made on reporting modifications in publications using the measures.
The issues open a dialogue about what appropriate guidelines would be for researchers adapting measures in studies of ethnically diverse populations.
PMCID: PMC3768261  PMID: 22495768
Measurement; modifying measures; adapting measures; minority aging; health disparities
15.  Development and Validation of a Questionnaire to Detect Behavior Change in Multiple Advance Care Planning Behaviors 
PLoS ONE  2013;8(9):e72465.
Advance directives have traditionally been considered the gold standard for advance care planning. However, recent evidence suggests that advance care planning involves a series of multiple discrete behaviors for which people are in varying stages of behavior change. The goal of our study was to develop and validate a survey to measure the full advance care planning process.
The Advance Care Planning Engagement Survey assesses “Process Measures” of factors known from Behavior Change Theory to affect behavior (knowledge, contemplation, self-efficacy, and readiness, using 5-point Likert scales) and “Action Measures” (yes/no) of multiple behaviors related to surrogate decision makers, values and quality of life, flexibility for surrogate decision making, and informed decision making. We administered surveys at baseline and 1 week later to 50 diverse, older adults from San Francisco hospitals. Internal consistency reliability of Process Measures was assessed using Cronbach's alpha (only continuous variables) and test-retest reliability of Process and Action Measures was examined using intraclass correlations. For discriminant validity, we compared Process and Action Measure scores between this cohort and 20 healthy college students (mean age 23.2 years, SD 2.7).
Mean age was 69.3 (SD 10.5) and 42% were non-White. The survey took a mean of 21.4 minutes (±6.2) to administer. The survey had good internal consistency (Process Measures Cronbach's alpha, 0.94) and test-retest reliability (Process Measures intraclass correlation, 0.70; Action Measures, 0.87). Both Process and Action Measure scores were higher in the older than younger group, p<.001.
A new Advance Care Planning Engagement Survey that measures behavior change (knowledge, contemplation, self-efficacy, and readiness) and multiple advance care planning actions demonstrates good reliability and validity. Further research is needed to assess whether survey scores improve in response to advance care planning interventions and whether scores are associated with receipt of care consistent with one's wishes.
PMCID: PMC3764010  PMID: 24039772
16.  Quality of life (QOL) of older adult community choral singers in Finland 
International psychogeriatrics / IPA  2013;25(7):1055-1064.
Enhancing quality of life (QOL) of older adults is an international area of focus. Identifying factors and experiences that contribute to QOL of older adults helps promote optimal levels of functioning. This study examines the relationship between perceived benefits associated with choral singing and quality of life (QOL) among community-dwelling older adults.
One hundred and seventeen older adults who sing in community choirs in Jyväskylä, Finland completed self-report measures of QOL (WHOQOL-Bref), depressive symptoms, and a questionnaire about the benefits of singing in choir. Correlational analyses and linear regression models were used to examine the association between the benefits of singing in choir and QOL.
Both correlation and regression analyses found significant relationships between the benefits of choral singing and three QOL domains: psychological, social relationships, and environment but not physical. These associations remained significant after adjusting for age and depressive symptoms. As hypothesized, older choral singers who reported greater benefits of choir singing had higher QOL in multiple domains. The older choral singers in the study also reported few symptoms of depression and high overall QOL and satisfaction with health.
Results suggest that singing in a community choir as an older adult may positively influence several aspects of QOL. These results suggest that community choral singing may one potential avenue for promoting quality of life in older adults.
PMCID: PMC3748797  PMID: 23574947
Music; choir; quality of life; aging
17.  Theory-Guided Selection of Discrimination Measures for Racial/Ethnic Health Disparities Research among Older Adults 
Journal of aging and health  2012;24(6):1018-1043.
Discrimination may contribute to health disparities among older adults. Existing measures of perceived discrimination have provided important insights but may have limitations when used in studies of older adults. This paper illustrates the process of assessing the appropriateness of existing measures for theory-based research on perceived discrimination and health.
First we describe three theoretical frameworks that are relevant to the study of perceived discrimination and health – stress-process models, life course models, and the Public Health Critical Race praxis. We then review four widely-used measures of discrimination, comparing their content and describing how well they address key aspects of each theory, and discussing potential areas of modification.
Using theory to guide measure selection can help improve understanding of how perceived discrimination may contribute to racial/ethnic health disparities among older adults.
PMCID: PMC3693449  PMID: 22451527
race/ethnicity; discrimination; disparities; measurement
18.  Self-reported interoceptive awareness in primary care patients with past or current low back pain 
Journal of Pain Research  2013;6:403-418.
Mind–body interactions play a major role in the prognosis of chronic pain, and mind–body therapies such as meditation, yoga, Tai Chi, and Feldenkrais presumably provide benefits for pain patients. The Multidimensional Assessment of Interoceptive Awareness (MAIA) scales, designed to measure key aspects of mind–body interaction, were developed and validated with individuals practicing mind–body therapies, but have never been used in pain patients.
We administered the MAIA to primary care patients with past or current low back pain and explored differences in the performance of the MAIA scales between this and the original validation sample. We compared scale means, exploratory item cluster and confirmatory factor analyses, scale–scale correlations, and internal-consistency reliability between the two samples and explored correlations with validity measures.
Responses were analyzed from 435 patients, of whom 40% reported current pain. Cross-sectional comparison between the two groups showed marked differences in eight aspects of interoceptive awareness. Factor and cluster analyses generally confirmed the conceptual model with its eight dimensions in a pain population. Correlations with validity measures were in the expected direction. Internal-consistency reliability was good for six of eight MAIA scales. We provided specific suggestions for their further development.
Self-reported aspects of interoceptive awareness differ between primary care patients with past or current low back pain and mind–body trained individuals, suggesting further research is warranted on the question whether mind–body therapies can alter interoceptive attentional styles with pain. The MAIA may be useful in assessing changes in aspects of interoceptive awareness and in exploring the mechanism of action in trials of mind–body interventions in pain patients.
PMCID: PMC3677847  PMID: 23766657
interoception; body awareness; low back pain; questionnaire
19.  A comparison of item response theory-based methods for examining differential item functioning in object naming test by language of assessment among older Latinos 
Object naming tests are commonly included in neuropsychological test batteries. Differential item functioning (DIF) in these tests due to cultural and language differences may compromise the validity of cognitive measures in diverse populations. We evaluated 26 object naming items for DIF due to Spanish and English language translations among Latinos (n=1,159), mean age of 70.5 years old (Standard Deviation (SD)±7.2), using the following four item response theory-based approaches: Mplus/Multiple Indicator, Multiple Causes (Mplus/MIMIC; Muthén & Muthén, 1998–2011), Item Response Theory Likelihood Ratio Differential Item Functioning (IRTLRDIF/MULTILOG; Thissen, 1991, 2001), difwithpar/Parscale (Crane, Gibbons, Jolley, & van Belle, 2006; Muraki & Bock, 2003), and Differential Functioning of Items and Tests/MULTILOG (DFIT/MULTILOG; Flowers, Oshima, & Raju, 1999; Thissen, 1991). Overall, there was moderate to near perfect agreement across methods. Fourteen items were found to exhibit DIF and 5 items observed consistently across all methods, which were more likely to be answered correctly by individuals tested in Spanish after controlling for overall ability.
PMCID: PMC3588164  PMID: 23471423
Item response theory; differential item functioning; object naming test; Hispanic/Latinos; Spanish
20.  The Patient-reported Clinicians’ Cultural Sensitivity Survey (CCSS): A Field Test among Older Latino Primary Care Patients 
Patient-reported measures of clinicians’ cultural sensitivity are important to assess comprehensively quality of care among ethnically diverse patients and may help address persistent health inequities.
Create a patient-reported, multidimensional survey of clinicians’ cultural sensitivity to cultural factors affecting quality of care.
Using a comprehensive conceptual framework, items were written and field-tested in a cross-sectional telephone survey. Multitrait scaling and factor analyses were used to develop measures.
Setting and Participants
Latino patients ≥ age 50 from primary care practices in California.
Main Variables Studied
35 items hypothesized to assess clinicians’ sensitivity
Main Outcomes Measures
Validity and reliability of cultural sensitivity measures.
Twenty-nine of 35 items measuring 14 constructs were retained. Eleven measures assessed sensitivity issues relevant to all participants: complementary and alternative medicine; mind-body connections; causal attributions; preventive care; family involvement; modesty; prescription medications; spirituality; physician discrimination due to education; physician discrimination due to race/ethnicity; and staff discrimination due to race/ethnicity. Three measures were group specific: two to limited English proficient patients (sensitivity to language needs and discrimination due to language) and one to immigrant (sensitivity to immigrant status). Twelve multi-item scales demonstrated adequate reliability (alpha ≥ .68 except for Spanish discrimination due to education) and evidence of construct validity (item-scale correlations for all scales > .40 except for sensitivity to immigrant status). Two single item measures demonstrated sufficient construct validity to retain for further development.
Discussion and Conclusions
The Clinicians’ Cultural Sensitivity Survey can be used to assess the quality of care of older Latino patients.
PMCID: PMC3570254  PMID: 21223467
cultural sensitivity; cultural competence; Latinos; Hispanics; quality of care
21.  Patient perceptions of integrated care: confused by the term, clear on the concept 
Health care reform in the US has introduced terms such as ‘the patient-centered medical home’ and ‘integrated care’ that are often unclear and unfamiliar to patients. This study explored patient experiences with the functional domains of integrated care.
Theory and methods
Patients first wrote their definitions of integrated care and then participated in focus group discussions about their experiences with the health care system. Transcripts were analyzed for thematic content.
Forty-four patients participated in one of seven focus groups in San Francisco, CA in English and Spanish. Many patients were not clear about the meaning of the term integrated care. However, patients described experiences largely reflected in an existing conceptual model of integrated care and the importance of coordination within and across teams and with community resources, continuity and sharing of information, and patient engagement. Patients with high medical needs described the ubiquitous challenges they faced in experiencing coordinated care.
Patients may not understand the term integrated care but are relatively clear on what the concept of integrated care entails and support its successful implementation. Patients and their families are at the center of integrated care, and health systems need to support and empower them to successfully navigate the medical neighborhood.
PMCID: PMC3653280  PMID: 23687476
patient centered experiences; integrated care; framework
22.  The Live Well, Be Well Study: A Community-Based, Translational Lifestyle Program to Lower Diabetes Risk Factors in Ethnic Minority and Lower–Socioeconomic Status Adults 
American Journal of Public Health  2012;102(8):1551-1558.
We evaluated a community-based, translational lifestyle program to reduce diabetes risk in lower–socioeconomic status (SES) and ethnic minority adults.
Through an academic–public health department partnership, community-dwelling adults at risk for diabetes were randomly assigned to individualized lifestyle counseling delivered primarily via telephone by health department counselors or a wait-list control group. Primary outcomes (6 and 12 months) were fasting glucose level, triglycerides, high- and low-density lipoprotein cholesterol, weight, waist circumference, and systolic blood pressure. Secondary outcomes included diet, physical activity, and health-related quality of life.
Of the 230 participants, study retention was 92%. The 6-month group differences for weight and triglycerides were significant. The intervention group lost 2 pounds more than did the control group (P = .03) and had decreased triglyceride levels (difference in change, 23 mg/dL; P = .02). At 6 months, the intervention group consumed 7.7 fewer grams per day of fat (P = .05) and more fruits and vegetables (P = .02) than did control participants.
Despite challenges designing effective translational interventions for lower-SES and minority communities, this program modestly improved some diabetes risk factors. Thus, individualized, telephone-based models may be a promising alternative to group-based interventions.
PMCID: PMC3395772  PMID: 22698027
23.  An Innovative Multiphased Strategy to Recruit Underserved Adults into a Randomized Trial of a Community-Based Diabetes Risk Reduction Program 
The Gerontologist  2011;51(Suppl 1):S82-S93.
Purpose: To conduct and evaluate a two-phased community-based approach to recruit lower socioeconomic status, minority, or Spanish-speaking adults at risk of developing diabetes to a randomized trial of a lifestyle intervention program delivered by a public health department. Design: Within geographic areas comprising our target population, 4 community organizations provided local space for conducting the study and program. Phase I—outreach in venues surrounding these organizations—included diabetes education, a short diabetes risk appraisal (DRA), and diabetes risk screening based on a fasting fingerstick glucose test. Phase II—trial recruitment—began concurrently for those found to be at risk of developing diabetes in Phase I by explaining the study, lifestyle program, and research process. Those interested and eligible enrolled in the 1-year study. Results: Over 2 years, approximately 5,110 individuals received diabetes education, 1,917 completed a DRA, and 1,164 were screened of which 641 (55%) had an elevated fingerstick result of ≥106 mg/dl. Of the study sampling frame—persons over age 25 at risk of developing diabetes (N = 544)—238 (43%) enrolled in the trial; of those who were study eligible (n = 427), 56% enrolled. In the final sample, mean age was 56 years (SD = 17), 78% were ethnic minorities, 32% were Spanish-speaking, and 15% had a high school education or less. Implications: Providing diabetes health education and screening prior to study recruitment may help overcome barriers to research participation in underserved communities, thus helping address difficulties recruiting minority and older populations into research, particularly research pertaining to chronic disease risk factors.
PMCID: PMC3092977  PMID: 21565823
Translational research; Recruitment; Health education; Minority populations; Academic–Community partnership
24.  Body Awareness: a phenomenological inquiry into the common ground of mind-body therapies 
Enhancing body awareness has been described as a key element or a mechanism of action for therapeutic approaches often categorized as mind-body approaches, such as yoga, TaiChi, Body-Oriented Psychotherapy, Body Awareness Therapy, mindfulness based therapies/meditation, Feldenkrais, Alexander Method, Breath Therapy and others with reported benefits for a variety of health conditions. To better understand the conceptualization of body awareness in mind-body therapies, leading practitioners and teaching faculty of these approaches were invited as well as their patients to participate in focus groups. The qualitative analysis of these focus groups with representative practitioners of body awareness practices, and the perspectives of their patients, elucidated the common ground of their understanding of body awareness. For them body awareness is an inseparable aspect of embodied self awareness realized in action and interaction with the environment and world. It is the awareness of embodiment as an innate tendency of our organism for emergent self-organization and wholeness. The process that patients undergo in these therapies was seen as a progression towards greater unity between body and self, very similar to the conceptualization of embodiment as dialectic of body and self described by some philosophers as being experienced in distinct developmental levels.
PMCID: PMC3096919  PMID: 21473781
25.  Changes in Patient Perceptions and Quality of Life Following Ablation in Patients with Supraventricular Tachycardia 
It remains unclear which symptom experiences and aspects of quality of life (QoL) change after ablation in patients with supraventricular tachycardia (SVT).
To determine how patient perceptions of symptoms and QoL change following ablation, we used a single group pre-postest design.
Patients with SVT (n=52; mean age=41 ± 17 yrs, 65% female) completed generic and disease specific measures, at baseline and one month after ablation.
Significant improvement after ablation was noted in virtually all measures (p < 0.05). Patients reported reductions from baseline in frequency and duration of episodes, number of symptoms, and impact of SVT on routine activities. All symptoms decreased in prevalence; however, no symptoms were completely eliminated at one month follow-up. Women reported larger symptom and QoL change scores than men after ablation.
Despite the small sample, statistically significant improvement was found following ablation in a variety of symptoms and QoL indices.
PMCID: PMC2817962  PMID: 20109982
Arrhythmia; Quality of Life; Symptoms; Catheter Ablation; Women's Health

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