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.
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.
Measurement; modifying measures; adapting measures; minority aging; health disparities
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.
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.
Music; choir; quality of life; aging
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).
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.
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.
Quality of care; race; ethnicity; measurement; measurement invariance; factorial invariance; physician-patient communication; physician-patient interaction
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.
Latinos; Hispanics; randomized trial; response rate; research participation
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.
race/ethnicity; discrimination; disparities; measurement
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.
interoception; body awareness; low back pain; questionnaire
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.
Item response theory; differential item functioning; object naming test; Hispanic/Latinos; Spanish
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.
cultural sensitivity; cultural competence; Latinos; Hispanics; quality of care
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.
patient centered experiences; integrated care; framework
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.
Translational research; Recruitment; Health education; Minority populations; Academic–Community partnership
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).
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.
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.
Patient satisfaction; patient–physician communication; interpersonal care; race; ethnicity
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.
Arrhythmia; Quality of Life; Symptoms; Catheter Ablation; Women's Health
There are no disease-specific questionnaires to measure patient sensitive outcomes in arrhythmia patients. We report the development and preliminary psychometric testing of the Patient Perception of Arrhythmia Questionnaire (PPAQ). The PPAQ was developed using formative research, exploratory factor analysis, expert review, pilot study, and regression. The PPAQ measures frequency and duration of episodes, symptoms, impact on daily activities, and restricted activity days. After preliminary content validation, the responsiveness of the PPAQ was tested in 103 arrhythmia patients. The measures showed good sensitivity and reliability. Preliminary construct validation was supported by significant differences (p<.001) among groups of arrhythmia patients consistent with clinical patterns. Preliminary evidence from patients with supraventricular arrhythmias suggests that the questionnaire has acceptable psychometrics and could be useful in future studies of arrhythmia patients.
Symptoms; Supraventricular Tachycardia; Arrhythmias; Measurement; Women’s Health
Low formal education level is becoming accepted as a risk factor for Alzheimer's disease (AD). Though increasing attention has been paid to educational quality differences, no prior studies have addressed participants' own characterization of their overall performance in school. We examined whether self-assessed school performance is associated with AD beyond the effects of educational level alone.
Participants were drawn from the population-representative Aging, Demographics and Memory Study (ADAMS), 2000-2002. ADAMS participants were asked about their performance in school; possible response options were ‘above average,’ ‘average,’ or ‘below average’. ADAMS participants also had a full neuropsychological battery and were given a research diagnosis of possible/probable AD.
The 725 participants (mean age 81.8 years, 59% female, and 16% African-American) varied in their educational performance: 29% reported ‘above average’; 64% ‘average’; and 7% reported ‘below average’ school performance. Participants with lower self-assessed school performance had higher proportions of AD: eleven percent of participants with above average self-assessed performance had AD; 12 percent of participants with ‘average’ performance and 26% of participants with ‘below average’ performance (p<0.001). After controlling for subjects' years in school, literacy test score(W-RAT), age, sex, race/ethnicity, and ApoE-ε4 status, socioeconomic status and self-reported comorbidity, respondents with ‘below average’ self-assessed school performance were 4 times more likely to have AD compared to those who had average performance.(OR 4.0; 95% CI 1.2-14) Above average' and ‘average’ self-assessed school performance did not increase or decrease the odds of AD.(OR 0.9; 95% CI 0.5-1.7)
We suggest an association between ‘below average’ self-assessed school performance and AD beyond the known association with formal education. Efforts to increase cognitive reserve through better school performance in addition to increasing the number of years of formal education in early life may be important to reduce vulnerability throughout the life course.
Alzheimer's Disease; Education; cognition; race; ethnicity
We examined sexual function in overweight and obese women with urinary incontinence, and evaluated the effects of an intensive behavioral weight reduction intervention on sexual function in this population.
Materials and Methods:
A total of 338 overweight and obese women reporting 10 or more incontinence episodes weekly were randomized to an intensive behavioral change (226) or structured education program (112) for 6 months. Sexual function was assessed using self-administered questionnaires. Multivariate regression was used to examine factors associated with baseline and 6-month change in sexual function as well as intervention effects.
Two-thirds of participants (233) were sexually active at baseline but more than half (188) reported low desire and a quarter (91) were sexually dissatisfied. More than half of sexually active participants (123) reported problems with arousal, lubrication, orgasm or incontinence during sex. Compared to controls women in the intervention group demonstrated a borderline increase in frequency of sexual activity at 6 months (OR 1.34, 95% CI 0.99–1.81, p = 0.06) but no differences in satisfaction (OR 1.28, 95% CI 0.83–1.99, p = 0.26), desire (OR 1.12, 95% CI 0.79–1.61, p = 0.52) or problems (β ± SE 0.03 ± 0.07, p = 0.68 for intervention effects on problems score). Neither clinical incontinence severity nor body mass index was independently associated with baseline or 6-month change in function (p >0.10 for all).
Sexual dysfunction is common in overweight and obese women with incontinence but the severity of this dysfunction may not be directly related to the severity of incontinence or obesity. An intensive 6-month behavioral weight reduction intervention did not significantly improve sexual function in this population relative to controls.
sexual behavior; urinary incontinence; obesity; weight loss
Illness-related stigma remains a serious problem in the management of HIV disease in Africa. This article describes a series of study phases conducted to develop and validate an instrument to measure HIV/AIDS-related stigma as perpetrated and experienced by nurses. Data were collected in Lesotho, Malawi, South Africa, Swaziland and Tanzania, from 2004-2006. The first phase was a qualitative study with focus group participants (n = 251) to gather emic and etic descriptions of HIV/AIDS-related stigma in the five countries. Based on the qualitative data, a 46-item instrument was developed and tested during a second phase in the same five countries (n = 244). The result of this phase was a 33-item, three-factor instrument with an average Cronbach alpha of 0.85. A third phase tested the instrument in 1474 nurses. The result was a final 19-item instrument, the HIV/AIDS Stigma Instrument - Nurse (HASI-N), comprised of two factors (Nurses Stigmatizing Patients and Nurses Being Stigmatized) with a Cronbach alpha of 0.90. Concurrent validity was tested by comparing the level of stigma with job satisfaction and quality of life. A significant negative correlation was found between stigma and job satisfaction. The HASI-N is the first inductively derived instrument measuring stigma experienced and enacted by nurses. It has the potential to be used not only to measure stigma, but also to develop stigma-reduction interventions.
HIV/AIDS; stigma; Africa; measurement; nurses
Primary care providers have limited time for physical activity counseling. They can optimize counseling time by referring patients to community resources for more comprehensive support. To facilitate referrals, resource guides (lists of community opportunities with descriptive information) are often created but seldom used. We elicited the detailed opinions of providers about how to make resource guides more useful for them.
We asked a convenience sample of health care providers open-ended questions about resource guide usefulness. Providers included 7 physicians, 6 physical/occupational therapists, 5 registered nurses, and 2 nurse practitioners practicing in diverse settings. We identified key themes using grounded theory methodology.
All participants thought resource guides were potentially useful, particularly providers who worked in communities that were socioeconomically or culturally different from their own. Perceived benefits included providing easy access to information, facilitating specific activity recommendations, and reminding health care providers about the scope of available opportunities. Participants cautioned that resource guides were not a substitute for individual recommendations or provider counseling. They said resource guide usefulness was limited by inconvenience, frustration with outdated entries, and discomfort referring patients to programs without personal experience of program quality. Providers offered suggestions for useful information to include in the resource guides.
Resource guides may offer a critical link between clinical services and community resources. Integrating guides with existing clinical systems, incorporating mechanisms for frequent updating, and providing multiple copies will help address provider concerns. Web-based resource guides may help achieve these goals.
Mandatory work hour limitations for residents began in July 2003. There has been little evaluation of the impact of the new limitations on Internal Medicine residency training.
To assess Internal Medicine residents’ perceptions of the impact of work hour limitations on clinical experiences, patient care, resident education, and well-being, and their compliance with the limitations.
DESIGN AND PARTICIPANTS
Cross-sectional survey administered to Internal Medicine residents at 1 large U.S. teaching hospital.
Resident perceptions using 5-point Likert scales, and self-reported compliance. Exploratory factor analysis was used to identify underlying domains and develop scales.
The survey response rate was 85%. Five domains were identified by factor analysis: 1) clinical experience, 2) patient care and safety, 3) communication, 4) satisfaction with training, and 5) work–rest balance. Residents perceived work hour limitations to have a negative impact on clinical experience (mean scale score 1.84, 1 = negative, 5 = positive), patient care and safety (2.64), and communication domains (1.98). Effects on satisfaction (3.12) and work–rest balance domains (2.95) were more positive. Senior residents perceived more negative effects of work hour limitations than interns. Compliance was difficult; 94% interns and 70% residents reported violating work hour limits. Patient care and teaching duties were the main reasons for work hour violations.
This study suggests that the current work hour limitations may be having unintended negative consequences on residency training. Ongoing monitoring to evaluate the impact of program changes as a result of work hour regulation is crucial to improving residency training.
work hour limitations; residency; survey; factor analysis
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.
Although research has found that childhood socioeconomic status (SES) is associated with physical and mental health in mid- and later life, most of these studies used conventional, single dimension SES measures for the childhood period such as household income or educational attainment of parents. Life course and health disparities research would benefit from identification and measurement of a variety of childhood social and economic experiences and opportunities that might affect health in later life.
This study utilized qualitative research methods to identify key dimensions of childhood experiences related to SES. We conducted in-depth interviews with 25 adults age 55 to 80 years from diverse economic and ethnic backgrounds. Topics included home, neighborhood, school, and work experiences during early childhood and adolescence. Interviews were audio-taped and transcripts were coded to identify thematic domains.
We identified eight thematic domains, many of which had clear subdomains: home and family circumstances, neighborhood, work and money, potential for advancement through schooling, school quality and content, discrimination, influence and support of adults, and leisure activities. These domains highlight individual characteristics and experiences and also economic and educational opportunities.
These domains of childhood social and economic circumstances add breadth and depth to conventional conceptualization of childhood SES. When the domains are translated into a measurement tool, it will allow for the possibility of classifying people along multiple dimensions, such as from a low economic circumstance with high levels of adult support.
Racial and ethnic disparities in health and health care have been documented; the elimination of such disparities is currently part of a national agenda. In order to meet this national objective, it is necessary that measures identify accurately the true prevalence of the construct of interest across diverse groups. Measurement error might lead to biased results, e.g., estimates of prevalence, magnitude of risks, and differences in mean scores. Addressing measurement issues in the assessment of health status may contribute to a better understanding of health issues in cross-cultural research.
To provide a brief overview of issues regarding measurement in diverse populations.
Approaches used to assess the magnitude and nature of bias in measures when applied to diverse groups include qualitative analyses, classic psychometric studies, as well as more modern psychometric methods. These approaches should be applied sequentially, and/or iteratively during the development of measures.
Investigators performing comparative studies face the challenge of addressing measurement equivalence, crucial for obtaining accurate results in cross-cultural comparisons.
Measurement; cross-cultural; health disparities
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).
MEASUREMENTS AND RESULTS
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.
recruitment; telephone survey; African Americans; Latinos; physician-patient communication