Dharma E. Cortés

Biculturality among Puerto Rican adults in the United States

Identified the concept of acculturation as a cornerstone of immigration research, while questioning assumptions about zero-sum cultural change in acculturation scales and in procedures assessing biculturality. Involvements in the host society culture and the culture of origin should be assessed separately in order to reflect the complexities of the cultural interactions immigrants and their offspring experience. To evaluate this prescription, we convened focus groups of Puerto Rican adults to discuss their cultural experiences in Puerto Rico and in the United States. Discussions were content analyzed to develop acculturation items. Factor analysis of the responses of 403 first- and second-generation adults yielded two general factors, involvement in American culture and involvement in Puerto Rican culture, which demonstrated modest reliability, relative independence, and moderate correlations with traditional acculturation scale validators. Results of the study challenge the assumption of mutual cultural exclusivity in acculturative change; enable the measurement of degree of biculturality; and provide future directions for the assessment of acculturation in domains other than language usage. The concept of acculturation is integrated with recent formulations in community psychology which advocate a deeper and more extensive commitment to studying the implications of cultural phenomena and greater focus on the growing cultural diversity in the United States.

Incorporating the cultural value of respeto into a framework of Latino parenting.

Latino families face multiple stressors associated with adjusting to United States mainstream culture that, along with poverty and residence in inner-city communities, may further predispose their children to risk for negative developmental outcomes. Evidence-based mental health treatments may require culturally informed modifications to best address the unique needs of the Latino population, yet few empirical studies have assessed these cultural elements. The current study examined cultural values of 48 Dominican and Mexican mothers of preschoolers through focus groups in which they described their core values as related to their parenting role. Results showed that respeto, family and religion were the most important values that mothers sought to transmit to their children. Respeto is manifested in several domains, including obedience to authority, deference, decorum, and public behavior. The authors describe the socialization messages that Latina mothers use to teach their children respeto and present a culturally derived framework of how these messages may relate to child development. The authors discuss how findings may inform the cultural adaptation of evidence-based mental health treatments such as parent training programs.

Modifiable Risk Factors for Suboptimal Control and Controller Medication Underuse Among Children With Asthma

OBJECTIVES. Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes. METHODS. We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as ≥4 symptom days, ≥1 symptom night, or ≥4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse. RESULTS. Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications. CONCLUSIONS. Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.

Views and Preferences of Low-Literate Hispanics Regarding Diabetes Education: Results of Formative Research:

Hispanics are twice as likely as non-Hispanic Whites to have diabetes and are also at higher risk for diabetes-related complications and poorer outcomes. The prevalence of diabetes is inversely related to educational status. Low literacy is common, especially among older Hispanics. Little literature exists on formative research to create diabetes education materials for this audience. Two focus groups assessed views and preferences for diabetes education of low-literate, low-income, non-English-speaking urban Caribbean and Central American Hispanics with diabetes, as well as utility of materials developed specifically for this population, as part of the preliminary work for a pilot study of a diabetes intervention. Implications for practitioners and researchers are discussed.

Massachusetts’ Health Care Reform Increased Access To Care For Hispanics, But Disparities Remain

Hispanics are more likely than any other racial or ethnic group in the United States to lack health insurance. This paper draws on quantitative and qualitative research to evaluate the extent to which health reforms in Massachusetts, a model for the Affordable Care Act of 2010, have reduced disparities in insurance coverage and access to health care. We found that rates of coverage and the likelihood of having a usual provider increased dramatically for Massachusetts Hispanics after the states reforms, but disparities remained. The increase in insurance coverage among Hispanics was more than double that experienced by non-Hispanic whites. Even so, in 2009, 78.9 percent of Hispanics had coverage, versus 96 percent of non-Hispanic whites. Language and other cultural factors remained significant barriers: Only 66.6 percent of Hispanics with limited proficiency in English were insured. One-third of Spanish-speaking Hispanics still did not have a personal provider in 2009, and 26.8 percent reported not seeing a doctor because of cost, up from 18.9 percent in 2005. We suggest ways to reduce such disparities through national health care reform, including simplified enrollment and reenrollment processes and assistance in finding a provider and navigating an unfamiliar care system.

Food Purchasing Selection Among Low-Income, Spanish-Speaking Latinos

BACKGROUND In the U.S., poverty has been linked to both obesity and disease burden. Latinos in the U.S. are disproportionately affected by poverty, and over the past 10 years, the percentage of overweight U.S. Latino youth has approximately doubled. Buying low-cost food that is calorie-dense and filling has been linked to obesity. Low-income individuals tend to favor energy-dense foods because of their low cost, and economic decisions made during food purchasing have physiologic repercussions. Diets based on energy-dense foods tend to be high in processed staples, such as refined grains, added sugars, and added fats. These diets have been linked to a higher risk of obesity, type 2 diabetes, and cardiovascular disease. PURPOSE This pilot study conducted ethnographic qualitative analyses combined with quantitative analyses to understand grocery shopping practices among 20 Spanish-speaking, low-income Latino families. The purpose was to analyze food selection practices in order to determine the effect of nutrition education on changes in shopping practices to later develop educational tools to promote selection of healthier food options. METHODS Participants received tailored, interactive, nutrition education during three to five home visits and a supermarket tour. Grocery store receipts for grocery purchases collected at baseline and at the end of the project were analyzed for each family to extract nutritional content of purchased foods. Nutritional content was measured with these factors in mind: quantity, calories, fats, carbohydrates, fiber, protein, and percentage of sugary beverages and processed food. Data were collected in 2010-2011 and analyzed in 2011-2012. RESULTS After receiving between three and five home-based nutrition education sessions and a supermarket tour over a 6-month period, many families adopted instructions on buying budget-friendly, healthier alternative foods. Findings indicate that participating families decreased the total number of calories and calories per dollar purchased from baseline to post-education (median total calories: baseline, 20,191; post-education, 15,991, p=0.008); median calories per dollar: baseline, 404; post-education, 320, p=0.008). The median grams of carbohydrates per dollar (baseline, 66, post-education, 45) and median calories from processed food (baseline, 11,000, post-education, 7845) were not reduced (p=0.06). CONCLUSIONS This pilot study demonstrated that grocery shopping practices are an important factor to address in nutrition education among Spanish-speaking, low-income individuals, and that there may be ways to encourage low-income, Latino families to purchase healthier foods. Findings challenged arguments suggesting that such an approach is not possible because of the high cost of healthier foods.

The Role of Patients’ Explanatory Models and Daily-Lived Experience in Hypertension Self-Management

ABSTRACTBACKGROUNDUncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients’ hypertension self-management have had lasting effects. Previous work has focused largely on patients’ beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients’ social contexts.OBJECTIVEThis study aims to explore how patients’ “explanatory models” of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors.DESIGNSemi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers.PARTICIPANTS (OR PATIENTS OR SUBJECTS)African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure.APPROACHWe conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients’ explanatory models, social context and hypertension management behaviors.RESULTSPatients’ perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients’ daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management.CONCLUSIONSDesigning interventions to improve patients’ hypertension self-management requires consideration of patients’ explanatory models and their daily-lived experience. We propose a new conceptual model — the dynamic model of hypertension self-management behavior — which incorporates these key elements of patients’ experiences.

The mental health relevance of idioms of distress. Anger and perceptions of injustice among New York Puerto Ricans.

Cultural sensitivity in mental health research is enhanced by examining the collective perceptions of members of ethnic groups about their own idiomatic expressions of distress. Such an examination was conducted with Puerto Ricans living in New York City, beginning with focus group discussions. Their prevailing idioms of distress, based upon themes of anger and injustice, were correlated widely with professionally developed measures of anxiety, depression, and somatization and with utilization of professional mental health care. By examining the relationship between idioms of distress, saliently volunteered by members of the ethnic ingroup, on the one hand, and professional care and assessments of mental health, on the other, we increase our culturally based understanding of mental health in the community

Associations between adherence to guidelines for antipsychotic dose and health status, side effects, and patient care experiences

Background:One approach to improving quality of care is to encourage physicians to follow evidence-based practice guidelines. Examples of evidence-based guidelines are the PORT recommendations for the treatment of schizophrenia. However, few studies have examined the relationship between adherence to guidelines and patient outcomes in clinical settings. Objective:The purpose of this article is to report the relationship between guideline adherence to antipsychotic medication dose and self-reported health status, side effects, and perceptions of care. Research Design:This report is based on a subsample of patients from a larger prospective observational study of disabled Massachusetts Medicaid beneficiaries treated for schizophrenia. Subjects:Participants were 329 acutely ill, vulnerable, high-risk Medicaid adult beneficiaries enrolled after visiting any 1 of 8 psychiatric emergency screening teams for hospital admission evaluation. Measures:Dose levels, symptoms, and functioning from medical records; self-reports as data collected from BASIS-32, SF-12, and CABHS; and paid health benefit claims for psychiatric treatment were measured. Results:Approximately 40% of the patients in this study had daily antipsychotic doses well above the recommended range, but there was no evidence that their health status was better than those on doses below 1000 CPZ units recommended for acute episodes. High-dose levels had no relationship to baseline symptom profile or referral source. Conclusions:There was no evidence that health status was better on higher-than-recommended doses, but we cannot conclude that lower doses for some would have led to poorer outcomes. Physicians who believe that higher doses are more therapeutic for patients need to demand rigorous effectiveness research that tests whether there are benefits of higher doses and determine the ratio of those benefits to the clinical costs, including the risk of side effects.

Cultural expression of psychiatric symptoms : Idioms of anger among Puerto Ricans

Increasing attention is being focused on the role of culture in psychological assessment and psychiatric diagnosis. In the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV, American Psychiatric Association, 1994), there are cultural considerations in applying the criteria of psychiatric disorders, as well as a glossary of culture-bound syndromes. There is a need for further research to clarify the cultural roots of expressive symptomatology. In the present study, focus groups conducted with Puerto Rican adults revealed that idioms of anger are salient to the mental health among a low socioeconomic status, inner-city population. Community and clinical samples of respondents (N = 531) were administered the idioms in a rating scale format. Factor analysis yielded dimensions expressive of aggression, assertiveness, and vindictiveness. These subscales correlated significantly with depressive and anxiety symptomatology, as measured by standardized instruments, and predicted clinical status. Results suggest that taking cultural expression of symptomatology into account enhances standard assessment of mental health.