Clinical Research with Older African Americans and Latinos

This study examines the social and health priorities of older African Americans and Latinos and their attitudes about participation in clinical research. Focus group discussions were conducted with older Latinos and African Americans, and a survey was mailed to key informants from 117 community-based organizations serving primarily older African Americans or Latinos. Results indicate that affordable housing, enough money to meet their needs, adequate transportation, and safer neighborhoods were urgent priorities for older Latinos and African Americans and superseded their health concerns. Distrust of researchers, lack of information, caregiver obligations, fear of experimentation, and lack of benefits were identified as barriers to research participation. Results indicate that community members are willing to participate in research provided they are fully informed of the research and perceive tangible benefits and congruence between the objectives of researchers and participants.

Developing a culturally competent peer support intervention for Spanish-speaking Latinas with breast cancer

Little research exists on the need for, barriers to, and acceptability and effectiveness of psychosocial support services among Latinas with breast cancer, despite their increased risks of psychosocial distress. This formative research study identifies barriers to and benefits and components of an effective peer support counselor intervention for Spanish-speaking Latinas recently diagnosed with breast cancer. Analysis was based on interviews of 89 Latino cancer patients referred to psychosocial services; 29 Spanish-speaking survivors of breast cancer; and 17 culturally competent advocates for Latinos with cancer. Results indicate that interventions should begin close to diagnosis; build self-care skills; be culturally competent and emotionally supportive; provide language appropriate cancer information; encourage self-expression; and address lack of access to and knowledge of services. Creating such psychosocial programs with input from survivors and advocates who have similar self-identities to patients would improve quality of life in diverse and underserved populations.

Interpersonal processes of care survey: patient-reported measures for diverse groups

OBJECTIVE

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.

CONCLUSIONS

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.

Using cognitive interviews to develop surveys in diverse populations

BACKGROUND

Conceptual equivalence of measures is essential in research that compares health across diverse racial/ethnic groups. Cognitive interviews are pretest methods to explore the conceptual equivalence of survey items. Systematic approaches for using these methods are emerging.

OBJECTIVE

We describe an interaction analysis (IA) approach using qualitative data analysis software to analyze transcripts of cognitive interviews in a study to develop a survey instrument of the quality of interpersonal processes of care of diverse patients. Cognitive interviews included standard administration of the survey followed by retrospective probes for selected items.

SUBJECTS

Interviews were completed with 48 Latino, black, and non-Latino white respondents 18 years of age or older with at least one doctor's visit in the past 12 months. Participants averaged 45.8 years in age (standard deviation [SD] = 18.4), 58% were women, and mean education was 14.7 years (SD = 4.0).

RESULTS

Problems were identified in 126 of 159 items (79%). Behavior coding identified 32 problematic items (20%). IA of the transcript of the survey and retrospective probes identified 94 additional problematic items (59%). IA often revealed the nature of the problems, enabling decisions to modify or drop items based on respondents' comments. Behavior coding and IA identified ethnic and language similarities and differences in the use of response sets and the interpretation of items.

CONCLUSIONS

IA and behavior coding of cognitive interview transcripts can identify efficiently problems with items and their source to increase the likelihood of the revised items being conceptually equivalent across ethnic groups.

Patients' perceptions of cultural factors affecting the quality of their medical encounters

OBJECTIVE

The aim of this study was to identify key domains of cultural competence from the perspective of ethnically and linguistically diverse patients.

DESIGN

The study involved one-time focus groups in community settings with 61 African-Americans, 45 Latinos and 55 non-Latino Whites. Participants' mean age was 48 years, 45% were women, and 47% had less than a high school education. Participants in 19 groups were asked the meaning of 'culture' and what cultural factors influenced the quality of their medical encounters. Each text unit (TU or identifiable continuous verbal utterance) of focus group transcripts was content analysed to identify key dimensions using inductive and deductive methods. The proportion of TUs was calculated for each dimension by ethnic group.

RESULTS

Definitions of culture common to all three ethnic groups included value systems (25% of TUs), customs (17%), self-identified ethnicity (15%), nationality (11%) and stereotypes (4%). Factors influencing the quality of medical encounters common to all ethnic groups included sensitivity to complementary/alternative medicine (17%), health insurance-based discrimination (12%), social class-based discrimination (9%), ethnic concordance of physician and patient (8%), and age-based discrimination (4%). Physicians' acceptance of the role of spirtuality (2%) and of family (2%), and ethnicity-based discrimination (11%) were cultural factors specific to non-Whites. Language issues (21%) and immigration status (5%) were Latino-specific factors.

CONCLUSIONS

Providing quality health care to ethnically diverse patients requires cultural flexibility to elicit and respond to cultural factors in medical encounters. Interventions to reduce disparities in health and health care in the USA need to address cultural factors that affect the quality of medical encounters.

The effectiveness of an advance notice letter on the recruitment of African Americans and Whites for a mailed patient satisfaction survey

OBJECTIVE

Evaluate an advance notice letter for enhancing patient satisfaction survey response rates in African Americans and Whites.

METHODS

Randomized trial of an advance notice letter (versus no letter) mailed two weeks prior to a mail satisfaction survey in a random sample of 600 African American and White patients ages 50 and older, stratified by ethnicity, sex, and age.

RESULTS

The advance letter was independently associated with a completed survey in Whites (odds ratio = 2.73; 95% confidence interval [CI] 1.66, 4.50), but not in African Americans (odds ratio = 1.24; 95% CI 0.76, 2.02). Being male was independently associated with returning a survey in Whites (odds ratio = 1.86; 95% CI 1.13, 3.06). Younger age (odds ratio = 0.98; 95% CI 0.96, 0.99) was independently associated with a completed survey in African Americans.

DISCUSSION

An advance letter prior to a satisfaction survey is associated with increased response rates in Whites, but not in African Americans.

Advancing health disparities research: can we afford to ignore measurement issues?

BACKGROUND

Research on racial and ethnic health disparities in the United States requires that self-report measures, developed primarily in mainstream samples, are appropriate when applied in diverse groups. To compare groups, mean scores must reflect true scores and have minimal bias, assumptions that have not been tested for many self-report measures used in this research.

OBJECTIVE

To identify conceptual and psychometric issues that need to be addressed to assure the quality of self-report measures being used in health disparities research.

METHODS

We present 2 broad conceptual frameworks for health disparities research and describe the main research questions and measurement issues for 4 key concepts hypothesized as potential mechanisms of health disparities: socioeconomic status, discrimination, acculturation, and quality of care. This article is based on a small conference convened by 6 Resource Centers for Minority Aging Research (RCMAR) measurement cores. We integrate written materials prepared for the conference by quantitative and qualitative measurement specialists and cross-cultural researchers, conference discussions, and current literature.

RESULTS

Problems in the quality of the conceptualizations and measures were found for all 4 concepts, and little is known about the extent to which measures of these concepts can be interpreted similarly across diverse groups. Many problems also apply to other concepts relevant to health disparities. We propose an agenda for accomplishing this challenging measurement research.

CONCLUSIONS

The current national commitment to reduce health disparities may be compromised without more research on measurement quality. Integrated, systematic efforts are needed to move this work forward, including collaborative efforts and special initiatives.

Population- and community-based recruitment of African Americans and Latinos: the San Francisco Bay Area Lung Cancer Study

Empiric data on recruitment of minorities into clinical or population studies are limited. The authors evaluated population- and community-based recruitment methods in a 1998-2001 case-control study of lung cancer among African Americans and Latinos. For lung cancer cases in the San Francisco Bay Area of California, rapid case ascertainment by the tumor registry combined with telephone screening identified 470 (9%) African Americans and 262 (5%) Latinos. When random digit dialing (RDD) and Health Care Financing Administration (HCFA) records failed to yield adequate numbers of controls in appropriate age-gender-ethnicity groups, community-based recruitment methods were used. Demographic characteristics and behavioral and occupational risk factors for controls, by recruitment method, were compared with those for lung cancer cases to evaluate potential bias. The average numbers of hours spent per control recruited were 18.6 for RDD, 11.4 for HCFA, and less than 1 for the community-based methods. The prevalence of smoking-related lung cancer risk factors was significantly higher among African-American community-based controls than for those identified through RDD (p < 0.005). Compared with HCFA controls, Latino RDD controls reported significantly higher cumulative smoking exposure (p < 0.05). Further assessment of strategies for successful recruitment of minority participants into epidemiologic studies is warranted.