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1.  Salud de Corazon: Cultural Resources for Cardiovascular Health among Older Hispanic Women 
The prevalence of cardiovascular disease risk factors in Hispanic women has been substantiated across studies. While many studies have focused on the impact of these risk factors, few qualitative studies have addressed cultural and contextual meanings of cardiovascular health promotion in this population. This research explored cultural resources for cardiovascular health promotion among older Hispanic women. A qualitative descriptive methodological design using focus groups with 7 Hispanic women was used. Culture provided an overarching perspective, guiding identification and choice of resources and supports in order to promote cardiovascular health. Themes included Living Tradition, Caring for Family, Connecting with Friends, Having Faith, and Moving as Life. Data provide an initial step toward generating a more complete understanding of perceived cultural resources for cardiovascular health in older Hispanic women. Researchers and clinicians are increasingly recognizing that individuals, families and communities uniquely define cultural and contextual meaning of cardiovascular health promotion.
PMCID: PMC3459313  PMID: 23024613
Hispanic Women; Cardiovascular Health Promotion; Cultural Resources; Older Adults
2.  Fitting a Bivariate Measurement Error Model for Episodically Consumed Dietary Components 
There has been great public health interest in estimating usual, i.e., long-term average, intake of episodically consumed dietary components that are not consumed daily by everyone, e.g., fish, red meat and whole grains. Short-term measurements of episodically consumed dietary components have zero-inflated skewed distributions. So-called two-part models have been developed for such data in order to correct for measurement error due to within-person variation and to estimate the distribution of usual intake of the dietary component in the univariate case. However, there is arguably much greater public health interest in the usual intake of an episodically consumed dietary component adjusted for energy (caloric) intake, e.g., ounces of whole grains per 1000 kilo-calories, which reflects usual dietary composition and adjusts for different total amounts of caloric intake. Because of this public health interest, it is important to have models to fit such data, and it is important that the model-fitting methods can be applied to all episodically consumed dietary components.
We have recently developed a nonlinear mixed effects model (Kipnis, et al., 2010), and have fit it by maximum likelihood using nonlinear mixed effects programs and methodology (the SAS NLMIXED procedure). Maximum likelihood fitting of such a nonlinear mixed model is generally slow because of 3-dimensional adaptive Gaussian quadrature, and there are times when the programs either fail to converge or converge to models with a singular covariance matrix. For these reasons, we develop a Monte-Carlo (MCMC) computation of fitting this model, which allows for both frequentist and Bayesian inference. There are technical challenges to developing this solution because one of the covariance matrices in the model is patterned. Our main application is to the National Institutes of Health (NIH)-AARP Diet and Health Study, where we illustrate our methods for modeling the energy-adjusted usual intake of fish and whole grains. We demonstrate numerically that our methods lead to increased speed of computation, converge to reasonable solutions, and have the flexibility to be used in either a frequentist or a Bayesian manner.
doi:10.2202/1557-4679.1267
PMCID: PMC3406506  PMID: 22848190
Bayesian approach; latent variables; measurement error; mixed effects models; nutritional epidemiology; zero-inflated data
3.  Diabetes, physical activity and breast cancer among Hispanic women 
Cancer epidemiology  2010;34(5):556-561.
Purpose
We assessed the association between diabetes and breast cancer and whether physical activity modified the effect of diabetes on breast cancer in Hispanic women.
Methods
We used data from a case-control study of breast cancer among Hispanic women aged 30 to 79 conducted between 2003 and 2008 on the Texas-Mexico border. In-person interviews were completed with 190 incident breast cancer cases ascertained through surgeons and oncologists, and 979 controls who were designated as both high-risk (n=511) and low-risk (N=468) for breast cancer (with respective response rates of 97%, 83% and 74%).
Results
After adjustment for menopausal status and mammography screening, there was no effect of diabetes on breast cancer risk (high-risk control group odds ratio [OR] 1.02, 95% confidence interval [CI] 0.71–1.48; low-risk control group OR 0.87, 0.58–1.30). Women who had a diabetes history and did not exercise were at no risk of breast cancer (OR 0.96, 95% CI 0.63–1.48) or a slightly reduced breast cancer risk (low-risk control group OR 0.72, 95% CI 0.46–1.15) depending on the control group used, while women with diabetes who did exercise had significantly reduced breast cancer risk (OR 0.41, 95% CI 0.21–0.83) regardless of the control group used (high-risk control group p-value for interaction=0.013, low-risk control group p-value for interaction 0.183).
Conclusions
Should other studies confirm our results, physical activity should be explored as a means of reducing breast cancer risk in diabetic women.
doi:10.1016/j.canep.2010.06.001
PMCID: PMC3069636  PMID: 20591760
breast cancer; diabetes; physical activity; case-control study
4.  Review of Intervention Studies Promoting Physical Activity in Hispanic Women 
Purpose
The objectives of this review were to: (a) provide a comprehensive review and evaluation of intervention studies designed to promote physical activity among Hispanic women; and (b) provide recommendations for future research involving Hispanic women in physical activity intervention research.
Methods
Computer and manual searches were conducted of articles in the English-language literature from 1980 to present.
Findings
Tweleve articles were evaluated, with emphasized physical activity intervention in Hispanic women. A review of current intervention research provides a starting point for determining salient approaches for intervention and evaluation, issues related to program implementation, and the strengths and limits of existing approaches.
Conclusions
Over the past 30 years, very few interventions have been conducted that examines foster physical activity among Hispanic women; those that include Hispanic women across ages support the need for interventions that build upon the strengths and address the limitations of this body of research.
doi:10.1177/0193945909351300
PMCID: PMC3152463  PMID: 20040732
5.  Wellness Motivation Theory in Practice 
Geriatric nursing (New York, N.Y.)  2009;30(2 Suppl):15-20.
doi:10.1016/j.gerinurse.2009.02.006
PMCID: PMC2691415  PMID: 19345859
6.  Prevalence of Physical Activity and Sedentary Behaviors by Metropolitan Status in 4th-, 8th-, and 11th-Grade Students in Texas, 2004-2005 
Preventing Chronic Disease  2008;6(1):A21.
Introduction
Research on geographic differences in children's physical activity (PA) engagement is limited. This study examined the prevalence of PA and sedentary behaviors in a probability sample of children in the 4th (mean age, 9.7 years; n = 7,907), 8th (mean age, 13.7 years; n = 8,827), and 11th (mean age 16.9 years; n = 6,456) grades by urban, suburban, and rural location in Texas.
Methods
Using data from the 2004-2005 School Physical Activity and Nutrition (SPAN) study, we conducted logistic regression analyses stratified by sex to assess associations of 6 PA indicators and 2 sedentary behavior indicators with metropolitan status.
Results
Urban 8th- and 11th-grade students reported the lowest prevalence of PA. Suburban or rural schools were significantly more likely than their urban counterparts to report higher school-based sports team participation in 8th graders (P = .001); higher vigorous PA (P = .01) and strengthening exercise (P = .01) in 11th-grade boys; and higher physical education attendance in 4th (P < .01) and 11th graders (P = .05). Sports team (P = .04) and other organized PA participation (P = .04) in urban 4th-grade girls and vigorous PA in urban 8th-grade boys (P = .04) were the only behaviors for which a significantly higher prevalence was reported compared with nonurban counterparts. We observed few significant geographic differences in prevalence of television watching and video game playing.
Conclusion
Several significant differences in PA behaviors were found by metropolitan status in this sample of public school students in Texas. Research is needed on availability of PA opportunities and PA barriers by metropolitan status to better understand the lower prevalence estimates reported in older urban children.
PMCID: PMC2644594  PMID: 19080027
7.  Predicting the Length of Stay of Patients Admitted for Intensive Care Using a First Step Analysis 
Predicting the Length of Stay of Patients Admitted for Intensive Care Using a First Step Analysis
For patients admitted to intensive care units (ICU), the length of stay in different destinations after the first day of ICU admission, has not been systematically studied. We aimed to estimate the average length of stay (LOS) of such patients in Colombia, using a discrete time Markov process. We used the maximum likelihood method and Markov chain modeling to estimate the average LOS in the ICU and at each destination after discharge from intensive care. Six Markov models were estimated, describing the LOS in each one of the Cardiovascular, Neurological, Respiratory, Gastrointestinal, Trauma and Other diagnostic groups from the ultimate primary reason for admission to ICU. Possible destinations were: the intensive care unit, ward in the same hospital, the high dependency unit/intermediate care area in the same hospital, ward in other hospital, intensive care unit in other hospital, other hospital, other location same hospital, discharge from same hospital and death. The stationary property was tested and using a split-sample analysis, we provide indirect evidence about the appropriateness of the Markov property. It is not possible to use a unique Markov chain model for each diagnostic group. The length of stay varies across the ultimate primary reason for admission to intensive care. Although our Markov models shown to be predictive, the fact that current available statistical methods do not allow us to verify the Markov property test is a limitation. Clinicians may be able to provide information about the hospital LOS by diagnostic groups for different hospital destinations.
doi:10.1007/s10742-006-0009-9
PMCID: PMC1828134  PMID: 18059977
discrete time; destination after intensive care unit; Markov chain

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