Jasmine Santoyo-Olsson

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 doctors 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.

Clinician ratings of interpreter mediated visits in underserved primary care settings with ad hoc, in-person professional, and video conferencing modes.

Linguistic interpretation ameliorates health disparities disfavoring underserved limited English-proficient patients, yet few studies have compared clinician satisfaction with these services. Self-administered clinician post-visit surveys compared the quality of interpretation and communication, visit satisfaction, degree of patient engagement, and cultural competence of visits using untrained people acting as interpreters (ad hoc), in-person professional, or video conferencing professional interpretation for 283 visits. Adjusting for clinician and patient characteristics, the quality of interpretation of in-person and video conferencing modes were rated similarly (OR 1.79, 95% CI 0.74, 4.33). The quality of in-person (OR 5.55, 95% CI 1.50, 20.51) and video conferencing (OR 3.10, 95% CI 1.16, 8.31) were rated higher than ad hoc interpretation. Self-assessed cultural competence was better for in-person versus video conferencing interpretation (OR 2.32, 95% CI 1.11, 4.86). Video conferencing interpretation increases access without compromising quality, but cultural nuances may be better addressed by in-person interpreters. Professional interpretation is superior to ad hoc (OR 4.15, 95% CI 1.43, 12.09).

The Live Well, Be Well Study: A Community-Based, Translational Lifestyle Program to Lower Diabetes Risk Factors in Ethnic Minority and Lower–Socioeconomic Status Adults

OBJECTIVES We evaluated a community-based, translational lifestyle program to reduce diabetes risk in lower-socioeconomic status (SES) and ethnic minority adults. METHODS Through an academic-public health department partnership, community-dwelling adults at risk for diabetes were randomly assigned to individualized lifestyle counseling delivered primarily via telephone by health department counselors or a wait-list control group. Primary outcomes (6 and 12 months) were fasting glucose level, triglycerides, high- and low-density lipoprotein cholesterol, weight, waist circumference, and systolic blood pressure. Secondary outcomes included diet, physical activity, and health-related quality of life. RESULTS Of the 230 participants, study retention was 92%. The 6-month group differences for weight and triglycerides were significant. The intervention group lost 2 pounds more than did the control group (P=.03) and had decreased triglyceride levels (difference in change, 23 mg/dL; P=.02). At 6 months, the intervention group consumed 7.7 fewer grams per day of fat (P=.05) and more fruits and vegetables (P=.02) than did control participants. CONCLUSIONS Despite challenges designing effective translational interventions for lower-SES and minority communities, this program modestly improved some diabetes risk factors. Thus, individualized, telephone-based models may be a promising alternative to group-based interventions.

Methods for Translating Evidence-Based Behavioral Interventions for Health-Disparity Communities

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.

Description of an academic community partnership lifestyle program for lower income minority adults at risk for diabetes.

Purpose Translating strategies and approaches from the successful clinically based Diabetes Prevention Program’s lifestyle intervention to community settings is a key next step. This article describes a lifestyle program developed in partnership by researchers at a major university and public health professionals at a local health department. Methods The Live Well, Be Well (LWBW) program was designed to meet the needs of lower income, minority, and low-literacy adults at risk for diabetes. It was adapted from interventions with demonstrated efficacy and delivered in Spanish and English by health department staff. The program consisted of a 6-month active phase and a 6-month maintenance phase and was primarily telephone based, with one in-person planning session and several group workshops. In-person and group sessions were held in convenient community-based settings. Counselors provided education and skills training to modify diet and increase physical activity. Self-selected and attainable goal-setting and action plans were emphasized to enhance self-efficacy. LWBW is the intervention component of a randomized trial with primary outcomes of fasting glucose, weight, and other clinical measures. Conclusions The program provides a unique translational model for implementing diabetes risk reduction programs for underserved populations. Individually tailored and non-prescriptive, it utilized existing health department infrastructure, focused on telephone counseling, used culturally appropriate, low-literacy materials, and was delivered in local, community-based facilities.

Inaccurate Language Interpretation and Its Clinical Significance in the Medical Encounters of Spanish-speaking Latinos.

Background:Limited English-proficient patients suffer poorer quality of care and outcomes. Interpreters can ameliorate these disparities; however, evidence is lacking on the quality of different interpretation modes. Objective:Compare accuracy of interpretation for in-person (IP) professional, professional videoconferencing (VC), and ad hoc (AH) interpretation. Design:A cross-sectional study of transcribed audiotaped primary care visits. Subjects:Subjects included 32 Spanish-speaking Latino patients and 14 clinicians. Measures:Independent coding of transcripts by 4 coders (2 were internists) for accurate and inaccurate interpretation instances. Unit of analysis was a segment of continuous speech or text unit (TU). Two internists independently verified inaccurate interpretation instances and rated their clinical significance as clinically insignificant, mildly, moderately, or highly clinically significant. Results:Accurate interpretation made up 70% of total coded TUs and inaccurate interpretation (errors) made up 30%. Inaccurate interpretation occurred at twice the rate for AH (54% of coded TUs) versus IP (25%) and VC (23%) interpretation, due to more errors of omission (P<0.001) and answers for patient or clinician (P<0.001). Mean number of errors per visit was 27, with 7.1% of errors rated as moderately/highly clinically significant. In adjusted models, the odds of inaccurate interpretation were lower for IP (OR=0.25, 95% CI, 0.19, 0.33) and VC (OR=0.31; 95% CI, 0.17, 0.56) than for AH interpreted visits; the odds of a moderately/highly clinically significant error were lower for IP (OR=0.25; 95% CI, 0.06, 0.99) than for AH interpreted visits. Conclusions:Inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared with professional IP or through VC. Professional VC interpretation may increase access to higher quality medical interpretation services.

Nuevo Amanecer: Results of a Randomized Controlled Trial of a Community-Based, Peer-Delivered Stress Management Intervention to Improve Quality of Life in Latinas With Breast Cancer

OBJECTIVES We evaluated a community-based, translational stress management program to improve health-related quality of life in Spanish-speaking Latinas with breast cancer. METHODS We adapted a cognitive-behavioral stress management program integrating evidence-based and community best practices to address the needs of Latinas with breast cancer. Spanish-speaking Latinas with breast cancer were randomly assigned to an intervention or usual-care control group. Trained peers delivered the 8-week intervention between February 2011 and February 2014. Primary outcomes were breast cancer-specific quality of life and distress, and general symptoms of distress. RESULTS Of 151 participants, 95% were retained at 6 months (between May 2011 and May 2014). Improvements in quality of life from baseline to 6 months were greater for the intervention than the control group on physical well-being, emotional well-being, breast cancer concerns, and overall quality of life. Decreases from baseline to 6 months were greater for the intervention group on depression and somatization. CONCLUSIONS Results suggest that translation of evidence-based programs can reduce psychosocial health disparities in Latinas with breast cancer. Integration of this program into community-based organizations enhances its dissemination potential.

An Innovative Multiphased Strategy to Recruit Underserved Adults into a Randomized Trial of a Community-Based Diabetes Risk Reduction Program

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.

Randomized controlled trial of Nuevo Amanecer: a peer-delivered stress management intervention for Spanish-speaking Latinas with breast cancer.

Background Latinas with breast cancer suffer symptom and psychosocial health disparities. Effective interventions have not been developed for or tested in this population. Purpose We describe community-based participatory research methods used to develop and implement the Nuevo Amanecer program, a culturally tailored, peer-delivered cognitive-behavioral stress management intervention for low-income Spanish-speaking Latinas with breast cancer, and unique considerations in implementing a randomized controlled trial to test the program in community settings. Methods We applied an implementation science framework to delineate the methodological phases used to develop and implement the Nuevo Amanecer program and trial, emphasizing community engagement processes. Results In phase 1, we established project infrastructure: academic and community co-principal investigators, community partners, community advisory board, steering committee, and funding. In phase 2, we identified three program inputs: formative research, a community best-practices model, and an evidence-based intervention tested in non-Latinas. In phase 3, we created the new program by integrating and adapting intervention components from the three sources, making adaptations to accommodate low literacy, Spanish language, cultural factors, community context, and population needs. In phase 4, we built community capacity for the program and trial by training field staff (recruiters and interventionists embedded in community sites), compensating field staff, and creating a system for identifying potential participants. In phase 5, we implemented and monitored the program and trial. Engaging community partners in all phases has resulted in a new, culturally tailored program that is suitable for newly diagnosed Latinas with breast cancer and a trial that is acceptable and supported by community and clinical partners. Lessons learned Engagement of community-based organizations and cancer survivors as research partners and hiring recruiters and interventionists from the community were critical to successful implementation in community settings. Having culturally and linguistically competent research staff with excellent interpersonal skills facilitated implementation. Facilitating and maintaining excellent communication among community partners was imperative to troubleshoot implementation issues. Randomization was challenging due to community concerns about assigning women to a control group. Patient privacy regulations and the need for extensive outreach to establish relationships between community partners and clinical sites hampered initial recruitment. Limitations These were resource-intensive processes to develop and implement the program that need to be compared to less-intensive alternatives. Conclusion Engaging community members in design and implementation of community-based programs and trials enhances cultural appropriateness and congruence with the community context. If the randomized trial demonstrates that the intervention is effective, it will fill a gap in evidence-based programs to address ethnic disparities in quality of life among Spanish-speaking Latinas with breast cancer.

The patient‐reported Clinicians’ Cultural Sensitivity Survey: a field test among older Latino primary care patients

Background  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.