Mammography screening rates among Chinese American women have been reported to be low. This study examines whether and how culture views and language ability influence mammography adherence in this mostly immigrant population. Asymptomatic Chinese American women (n = 466) aged 50 and older, recruited from the Washington, D.C. area, completed a telephone interview. Regular mammography was defined as having two mammograms at age-appropriate recommended intervals. Cultural views were assessed by 30 items, and language ability measured women’s ability in reading, writing, speaking, and listening to English. After controlling for risk perception, worry, physician recommendation, family encouragement, and access barriers, women holding a more Chinese/Eastern cultural view were significantly less likely to have had regular mammograms than those having a Western cultural view. English ability was positively associated with mammography adherence. The authors’ results imply that culturally sensitive and language-appropriate educational interventions are likely to improve mammography adherence in this population.
breast cancer screening; culture; minority health
This study investigates whether high-risk young adults’ perceptions of their likelihood of living to age 35 and of acquiring HIV are related to their substance abuse problems and risky sexual behaviors. The sample consists of data from the 72 and 87-month follow-up assessments of 449 juvenile offenders referred to probation in 1999 and 2000. Results indicate that believing one is likely to get HIV is associated with having more concurrent substance use problems and engaging in more risky sexual behaviors. Longitudinal analyses indicate that youth who think they are likely to get HIV are at greater risk for later substance abuse problems and risky sexual behaviors, though these results are only marginally significant. The results demonstrate that respondents are aware of some of the risks associated with their recent substance using and sexual behaviors, but that holding these perceptions does not result in a reduction of these behaviors.
School suspension may have unintended consequences in contributing to problem behaviors including school drop-out, substance use, and antisocial behavior. Tobacco use is an early-onset problem behavior, but prospective studies of the effects of suspension on tobacco use are lacking.
Longitudinal school-based survey of students drawn as a 2-stage cluster sample, administered in 2002 and 2003 in Washington State, United States and Victoria, Australia. The study uses statewide representative samples of students in Grades 7 and 9 (N = 3,599).
Rates of tobacco use were higher for Victorian than Washington State students. School suspension remained a predictor of current tobacco use at 12-month follow-up, after controlling for established risk factors including prior tobacco and other drug use for Grade 7 but not Grade 9 students.
School suspension is associated with tobacco use in early adolescence, itself an established predictor of adverse outcomes in young people. Findings suggest the need to explore process mechanisms and alternatives to school suspensions as a response to challenging student behavior in early adolescence.
adolescence; tobacco; suspension; cross-national study; longitudinal study; risk factors
Intervention and policy approaches targeting the societal factors that affect health literacy (e.g., educational systems) could have promise to improve health outcomes, but little research has investigated these factors. This study examined the associations between self-reported racial composition of prior educational and neighborhood contexts and health literacy among 1061 English- and Spanish-speaking adult community health center patients. We found that self-reported racial composition of high school was a significant predictor of health literacy among those who received schooling in the US, controlling for race/ethnicity, education, age, country of birth, and survey language. Black and Hispanic patients had significantly lower health literacy than white patients within educational strata among those schooled in the US. The findings revealed substantial disparities in health literacy. Self-reported racial composition of school context was a significant predictor of health literacy. Transdisciplinary, multi-level intervention approaches are likely to be needed to address the health literacy needs of this population.
health literacy; community health centers; health disparities; residential segregation
There is a growing emphasis on the role of organizations as settings for dissemination and implementation. Only recently has the field begun to consider features of organizations that impact on dissemination and implementation of evidence-based interventions. This manuscript identifies and evaluates available measures for 5 key organizational-level constructs: (1) leadership; (2) vision; (3) managerial relations; (4) climate; and (5) absorptive capacity. Overall the picture was the same across the five constructs—no measure was used in more than one study, many studies did not report the psychometric properties of the measures, some assessments were based on a single response per unit, and the level of the instrument and analysis did not always match. We must seriously consider the development and evaluation of a robust set of measures that will serve as the basis of building the field, allow for comparisons across organizational types and intervention topics, and allow a robust area of dissemination and implementation research to develop.
This study assessed effectiveness of an educational community intervention taught by promotoras de salud in reducing cardiovascular disease (CVD) risk among Hispanics using a structural equation modeling approach (SEM). Model development was guided by a social ecological framework proposing CVD risk reduction through improvement of protective health behaviors, health beliefs, contextual and social factors. Participants were 328 Hispanic adults with at least one CVD risk factor. SEM analyses assessed direct and indirect effects of intervention participation on CVD risk (Framingham score) and latent variables nutrition intake and health beliefs. The model fit was adequate (root mean square error approximation =.056 [90% confidence interval = .040, .072], comparative fit index =.967, normed fit index=.938, nonnormed fit index =.947). Intervention participation was associated with improved nutritional consumption, but not lower CVD risk. Stronger health beliefs predicted healthier nutritional habits. This project provided evidence for the adequacy of a conceptual framework that can be used to elicit new pathways towards CVD risk reduction among at-risk Hispanic populations.
Path Analysis; structural equation model; conceptual framework; Promotora; Community Health Worker; cardiovascular disease; Hispanic; Border; community; education; nutrition; promotoras de salud
This study examined factors associated with teens’ adherence to a multiple health behavior cancer preventive intervention. Analyses identified predictors of trial enrollment, run-in completion, and adherence (intervention initiation, number of sessions completed). Of 104 teens screened, 73% (n = 76) were trial-eligible. White teens were more likely to enroll than non-whites (χ2  df = 4.49, p = 0.04). Among enrolled teens, 76% (n = 50) completed the run-in; there were no differences between run-in completers and non-completers. A majority of run-in completers (70%, n = 35) initiated the intervention, though teens who initiated the intervention were significantly younger than those who did not (p < 0.05). The mean number of sessions completed was 5.7 (SD = 2.6; maximum = 8). After adjusting for age, teens with poorer session engagement (e.g., less cooperative) completed fewer sessions (B = -1.97, p = 0.003, R2 = 0.24). Implications for adolescent cancer prevention research are discussed.
adolescents; multiple health behavior change; cancer prevention; intervention adherence
The provision of culturally relevant yet evidence-based interventions has become crucial to global HIV prevention and treatment efforts. In Thailand, where treatment for HIV has become widely available, medication adherence and risk behaviors remain an issue for Thai youth living with HIV. Previous research on motivational interviewing (MI) has proven effective in promoting medication adherence and HIV risk reduction in the United States. However, to test the efficacy of MI in the Thai context a feasible method for monitoring treatment fidelity must be implemented. This article describes a collaborative three-step process model for implementing the MI Treatment Integrity (MITI) across cultures while identifying linguistic issues that the English-originated MITI was not designed to detect as part of a larger intervention for Thai youth living with HIV. Step 1 describes the training of the Thai MITI coder, Step 2 describes identifying cultural and linguistic issues unique to the Thai context, and Step 3 describes an MITI booster training and incorporation of the MITI feedback into supervision and team discussion. Throughout the process the research team collaborated to implement the MITI while creating additional ways to evaluate in-session processes that the MITI is not designed to detect. The feasibility of using the MITI as a measure of treatment fidelity for MI delivered in the Thai linguistic and cultural context is discussed.
cross-cultural research; HIV; MITI coding; motivational interviewing (MI); Thailand; treatment fidelity
Little is known about the most effective strategies to recruit male Latino smokers to cessation research studies. The purpose of this study was to identify efficient and cost effective research recruitment strategies for this priority population.
Male Latino smokers age 18 years or older were eligible. Five recruitment strategies were compared: two involved “proactive” face-to-face contact by research staff in formal or informal settings; three “reactive” strategies used mass media and flyers. Efficiency was based on the number of eligible men/number screened and the number enrolled/number screened. Incremental costs per added enrolled participant were calculated using micro-costing from a short-term, societal perspective. National data were used to estimate time costs exclusive of research and development.
Over 11 months, 1006 men were screened, 363 (36%) were eligible, and 294 (81% of those eligible) were enrolled. Proactive recruitment yielded more enrollees than reactive recruitment (256 vs. 38) but individuals were less likely to be eligible (34.0% vs. 68.9%) and to enroll in the study (27.4% vs. 62.3%). Average cost per enrollee was more than ten times lower for proactive than reactive approaches ($18 vs. $193). Proactive recruitment in informal settings was comparable in efficiency to reactive approaches and had the lowest incremental costs per additional enrollee.
This study suggests that approaching Latino smokers in informal community settings may be an efficient and cost-effective recruitment approach. These results are intended to guide tobacco researchers in recruiting male Latinos into smoking cessation trials in a cost effective and timely manner.
recruitment; Latino; smoking cessation
Major behavioral theories focus on proximal influences on behavior that are considered to be predominantly cognitive characteristics of the individual largely uninfluenced by social context. Social ecological models integrate multiple levels of influence on health behavior and are noted for emphasizing the interdependence of environmental settings and life domains. This theory-based article explains how social context is conceptualized in the social sciences and how the social science conceptualization differs from and can broaden the analytic approach to health behavior. The authors use qualitative data from the “Behavioral Constructs and Culture in Cancer Screening” study to illustrate our conceptualization of social context. We conclude that the incorporation into health behavior theory of a multidimensional socio-culturally oriented, theoretical approach to social context is critical to understand and redress health disparities in multicultural societies like that in the United States.
Social context; culture; health behavior theory; social science theory
This article highlights results from the Right Question Project–Mental Health (RQP-MH), an intervention designed to teach skills in question formulation and to increase patients’ participation in decisions about mental health treatment. Of participants in the RQP-MH intervention, 83% were from a Latino background, and 75% of the interviews were conducted in Spanish. The authors present the steps participants undertook in the process of becoming “activated” to formulate effective questions and develop decision-making skills in relation to their care. Findings suggest that patient activation and empowerment are interdependent because many of the skills (i.e., question formulation, direct patient–provider communication) required to become an “activated patient” are essential to achieve empowerment. Also, findings suggest that cultural and contextual factors can influence the experience of Latinos regarding participation in health care interactions. The authors provide recommendations for continued research on the patient activation process and further application of this strategy in the mental health field, especially with Latinos.
Latino; mental health; patient activation; patient communication; patient–provider communication
This study explored the characteristics of colorectal cancer (CRC) patients who accessed Internet-based health information as part of their symptom appraisal process prior to consulting a health care provider.
Newly diagnosed CRC patients who experienced symptoms prior to diagnosis were interviewed. Brief COPE was used to measure patient coping. Logistic and linear regressions were used to assess Internet use and appraisal delay.
Twenty-five percent of the sample (61/242) consulted the Internet prior to visiting a health care provider. Internet use was associated with having private health insurance (odds ratio [OR] = 2.55; 95% confidence interval [CI] = 1.20–5.43) and experiencing elimination symptoms (OR = 1.43; 95% CI = 1.14–1.80) and was marginally associated with age (OR = 0.96; 95% CI = 0.93–0.99). Internet use was not related to delayed medical care seeking.
Internet use did not influence decisions to seek medical care. The Internet provided a preliminary information resource for individuals who experienced embarrassing CRC symptoms, had private health insurance, and were younger.
appraisal delay; colorectal cancer; health information–seeking behavior; Internet; symptom appraisal
This study sought to evaluate the effectiveness of Project ACTS: About Choices in Transplantation and Sharing, which was developed to increase readiness for organ and tissue donation among African American adults. Nine churches (N = 425 participants) were randomly assigned to receive donation education materials currently available to consumers (control group) or Project ACTS educational materials (intervention group). The primary outcomes assessed at 1-year follow-up were readiness to express donation intentions via one’s driver’s license, donor card, and discussion with family. Results indicate a significant interaction between condition and time on readiness to talk to family such that participants in the intervention group were 1.64 times more likely to be in action or maintenance at follow-up than were participants in the control group (p = .04). There were no significant effects of condition or condition by time on readiness to be identified as a donor on one’s driver’s license and by carrying a donor card. Project ACTS may be an effective tool for stimulating family discussion of donation intentions among African Americans although additional research is needed to explore how to more effectively affect written intentions.
organ donation; intervention; minority health
The U.S. health care system is indeed challenged to provide effective, equitable, and efficient care for its citizens (Aday, Begley, Lairson, & Balkrishnan, 2004). The past decades have witnessed profound concern about the quality of care Americans receive, the equality of care across racial ethnic communities, and the escalating costs of private and public coverage. These concerns apply to the cancer care continuum, including screening. This commentary reflects on the methods, findings, and implications of the articles from the Behavioral Constructs and Culture in Cancer Screening (3Cs) in this Health Education & Behavior supplement. This commentary considers several important themes for consideration in applied screening research, including the (a) focus on population diversity in a cultural context, (b) domains of social context and their importance, and (c) contributions of an interdisciplinary team and mixed methods to research productivity. Although the articles focus on breast cancer screening, the methods, observations, and recommendations are relevant to other screening tests.
applied research; behavioral theory; screening test
Understanding factors that promote or prevent adherence to recommended health behaviors is essential for developing effective health programs, particularly among lower-income populations who carry a disproportionate burden of disease. We conducted in-depth qualitative interviews (n=64) with low-income Black and Latina women who shared the experience of requiring diagnostic follow-up after having an abnormal screening mammogram. In addition to holding negative and fatalistic cancer-related beliefs, we found that the social context of these women was largely defined by multiple challenges and major life stressors that interfered with their ability to attain health. Factors commonly mentioned included competing health issues, economic hardship, demanding caretaking responsibilities and relationships, insurance-related challenges, distrust of healthcare providers, and inflexible work policies. Black women also reported discrimination and medical mistrust, while Latinas experienced difficulties associated with immigration and social isolation. These results suggest that effective health interventions not only address change among individuals, but must also change healthcare systems and social policies in order to reduce health disparities.
Preventive care; Women’s Health; Health Disparities
smoking cessation; blue collar workers; mediation; occupational health; social contextual model
The Internet has emerged as an important tool for the delivery of health promotion and disease prevention interventions. Our community-based participatory research (CBPR) partnership developed and piloted CyBER/testing, a culturally congruent intervention designed to promote HIV testing among men who have sex with men (MSM) within existing Internet chat rooms. Using a quasi-experimental, single-group study design, cross-sectional data were collected from chat room participants, known as “chatters,” at pretest (n=346) and post-test (n=315). Extant profile data also were collected to describe the demographics of the online population. The intervention significantly increased self-reported HIV testing among chatters overall, increasing rates from 44.5% at pretest to nearly 60% at post-test (p<.001). Furthermore, chatters who reported having both male and female sexual partners had nearly 6 times the odds of reporting HIV testing at post-test. Findings suggest that chat room-based HIV testing intervention may increase testing among MSM who may be difficult to reach in traditional physical spaces.
A randomized controlled trial of two formats of a program ("Women Take PRIDE") to enhance management of heart disease by patients was conducted. Older women (N=575) were randomly assigned to a group or self-directed format or to a control group. Data regarding symptoms, functional health status and weight were collected at baseline, 4, 12 and 18 months. The formats produced different outcomes. At 18 months, the self-directed format was better than control in reducing the number (p ≤ 0.02), frequency (p ≤ 0.03) and bothersomeness (p ≤ 0.02) of cardiac symptoms. The self-directed format was also better than the group format in reducing symptom frequency of all types (p≤ 0.04). The group format improved ambulation at 12 months (p≤ 0.04), weight loss at 18 months (p≤.03), and group participants were more likely to complete the program (p ≤ 0.05). The availability of different learning formats could enhance management of cardiovascular disease by patients.
interventions for patients; heart disease; program evaluation; learning formats
This study tested the feasibility and acceptability of adding a reimbursable snack that meets the Institute of Medicine nutrition recommendations to an afterschool homework program for middle school students.
Snack menu was developed and administered to students attending an afterschool homework program over 12 weeks. In spring 2009, two cross-sections of middle school students completed study measures, including snack preferences. Key school personnel completed follow-up interviews assessing program feasibility.
Survey evaluations from 110 students at baseline and 113 at posttest suggested improved preferences for healthy snacks. Teacher supervisors (n = 3) and the assistant principal rated the pilot project as feasible and beneficial, whereas school food service (n = 3) rated the program unsustainable because of administration logistics and costs.
The addition of healthy snacks to afterschool programs was liked by students and teachers. However, policies that support simpler accountability procedures may be needed for school-based afterschool snack programs to be sustainable.
afterschool programs; school food environments; school-age children
This two PHASE evaluation documented the delivery and effectiveness of evidenced-based health education methods by regular staff to pregnant smokers. During PHASE 1, 436 Medicaid patients were screened and 416 (95%) gave consent: 334 non-smokers and 102 smokers. This historical Comparison (C) group was assessed to document the “normal” pre-Trial smoking prevalence, patient non-disclosure (deception), and cessation rates at the 1st prenatal visit and during care. After this study, a Formative Evaluation of SCRIPT methods was conducted among 139 Experimental group patients and 126 Control group patients. During the PHASE 2, 6514 patients were screened over a 36 month period: 1736 (27%) were smokers and 1340 (77%) gave consent. After randomization, 247 became ineligible. The remaining 1093 smokers received brief routine advice to quit. The Experimental group (N=544) also received: a “Commit To Quit” video, “A Pregnant Woman’s Guide to Quit Smoking”, and counseling. Self-reports and saliva were collected at baseline, ≥ 60 days, and ≤ 90 days postpartum for cotinine analyses to document cessation and significant reduction (SR) rates. The PHASE 1 Formative Evaluation documented a 24% non-disclosure rate at the onset of care. It also confirmed a significantly higher Experimental (17.3%) versus Control group (8.8%) cessation rate and Experimental versus Control group SR rates of 22% and 16%. During PHASE 2, unplanned policy changes, and delivery of E group counseling procedures to 15%–20% of C group patients, resulted in a final E group cessation rate of 12% and C group rate of 10%. The E group SR rate of 18%, however, was significantly higher than the C group SR rate of 13%. Effectiveness varied by the stability of clinic infrastructure, and degree of fidelity of staff performance of assessment and intervention procedures. The methods and results of this study will assist future health education programs for pregnant smokers to plan and conduct process and impact evaluations in prenatal care.
effectiveness; health education methods; SCRIPT; Medicaid prenatal care; pregnant smokers
Many nations have witnessed a dramatic increase in the prevalence of obesity and overweight across their population. Recognizing the influence of the household environment on energy balance has led many researchers to suggest that intergenerational interventions hold promise for addressing this epidemic. Yet few comprehensive reviews of intergenerational energy balance interventions have been undertaken. Our review of the literature over the past decade revealed that intergenerational intervention approaches to enhance energy balance use a broad array of designs, target populations, and theoretical models, making results difficult to compare and “best practices” challenging to identify. Additional themes include variation in how interventions incorporate the intergenerational component; an increasing acknowledgment of the importance of ecological models; variations in the location of interventions delivery; diversity in the intervention flexibility/structure, intensity, and duration; and variation in outcomes and measures used across studies. We discuss implications and future directions of intergenerational energy balance approaches.
health behavior; health promotion; intergenerational relations; intervention studies; family
This research analyzes motivations expressed by young, healthy, sedentary women before and after an exercise intervention. Young women (aged 18–30, n = 39) participated in focus groups or interviews during a 4-month exercise intervention. Afterward, 22 of these women and 20 controls completed physical activity diaries for 6 months and were interviewed. For the majority of women (n = 24), obligation to the study prevailed as the motivator during the intervention. Some (n = 15) became physically active for their own benefit. Afterward, exercisers and controls said they were physically active to feel better and/or healthy (n = 20), for body image and/or weight loss (n = 20), or both. Women expressed motivations for physical activity in ways that resonated with self-determination theory. Their commentaries expand on theory to include experiencing multiple motivations simultaneously and motivations shifting over time and in differing contexts. Social motivations were compelling, both those associated with societal values (research, health) and cultural trends (body image).
motivation; physical activity; young women
This report explores the level of detailed knowledge about the Tuskegee Syphilis Study (TSS) among 848 Blacks and Whites in three U.S. cities across an array of demographic variables. The Tuskegee Legacy Project (TLP) Questionnaire was used, which was designed to explore the willingness of minorities to participate in biomedical studies. A component of the TLP Questionnaire, the TSS Facts & Myths Quiz, consisting of seven yes/no factual questions, was used to establish respondents’ level of detailed knowledge on the TSS. Both Blacks and Whites had similar very low mean quiz score on the 7-point scale, with Blacks’ scores being slightly higher than Whites (1.2 vs. 0.9, p = .003). When analyzing the level of knowledge between racial groups by various demographic variables, several patterns emerged: (a) higher education levels were associated with higher levels of detailed knowledge and (b) for both Blacks and Whites, 30 to 59 years old knew the most about TSS compared with younger and older adult age groups. The findings show that much of the information that circulates in the Black and White communities about the TSS is false, often minimizing or understating the most egregious injustices that occurred. Health promotion and educational implications of these findings are offered and conclude that the findings should be used as a catalyst to explore local realities and sentiments regarding participation in biomedical research within the research philosophy and framework of community-based participatory research.
Tuskegee Syphilis Study; detailed knowledge between racial groups; community-based participatory research; African American; biomedical research; minorities; Blacks; health promotion
Health disparities among gay men (HIV, substance use, depression) have been described as a mutually occurring “syndemic” that is socially produced through two overarching dynamics: marginalization and migration. Although the syndemic theory proposes a developmental trajectory, it has been largely based on epidemiological studies of adult gay men and has not been examined using qualitative data from gay male adolescents and emerging adults describing their developmental experience. We conducted interviews with 54 HIV-positive gay and bisexual male adolescents and emerging adults at four sites in the United States. This study provides examples of developmental trajectories that help explain the early onset of socially produced health disparities among some gay male adolescents and emerging adults, but also the development of risk factors that may follow some gay men into adulthood.
adolescent gay men; emerging adulthood; syndemic; health disparities; HIV