José L. Calderón

Access to Vision Care in an Urban Low-Income Multiethnic Population

Objective: This study applied a well-known, recently revised theoretical model of healthcare access and utilization, the Behavioral Model for Vulnerable Populations, to examine the relationship between access to care and utilization of eye care services among a mutiethnic, predominately minority sample of residents from low-income public housing. Design: Population-based, cross-sectional survey of community sample. Setting: Urban Public Housing Communities in Los Angeles County, California. Participants: A geographically defined stratified random sample of 152 residents (86% Latino or African American) 40 years of age and older from three urban public housing communities. Results: Only 62% of our sample of persons 40 years and older had received an eye examination within the past 2 years. Sixty-one percent of participants reported having vision care coverage. Yet, one out of four respondents claimed that no health care provider had ever told them that they needed an eye-examination. Applying multiple logistic regression and controlling for a number of predisposing, enabling, and need-for-care characteristics, the variables 1) receiving advice from health care providers for eye examination (OR = 3.9, p < 0.01), 2) possessing coverage for eye-care (OR = 3.2, p < 0.01), and 3) having regular and continuity of medical care (OR = 2.4, p < 0.01) remained significant predictors of eye-examination within the past 2 years. Conclusion: This study documents significantly diminished utilization of eye care services relative to recommended guidelines for a low-income, predominately minority sample of residents from public housing communities. We documented no association between presence of diabetes or hypertension and recency of eye examination. Affordability, continuity, and regular sources of care, as well as receiving physician advice, remain the core factors significantly associated with receiving vision care. These results underscore the need for continued efforts to ensure that the medically underserved minority have access to vision care services. These findings also point toward the urgent need for educational and motivational interventions that encourage health care providers serving underserved communities to promote eye examination, particularly among diabetic patients, hypertensive patients, and other individuals at risk for eye-related disease and complications.

Variation in the Readability of Items Within Surveys

The objective of this studywas to estimate the variation in the readability of survey items within 2 widely used health-related quality-of-life surveys: the National Eye Institute Visual Functioning Questionnaire–25 (VFQ-25) and the Short FormHealth Survey, version 2 (SF-36v2). Flesch-Kincaid and Flesch Reading Ease formulas were used to estimate readability. Individual survey item scores and descriptive statistics for each survey were calculated. Variation of individual item scores from the mean survey score was graphically depicted for each survey. The mean reading grade level and reading ease estimates for the VFQ-25 and SF-36v2 were 7.8 (fairly easy) and 6.4 (easy), respectively. Both surveys had notable variation in item readability; individual itemreadability scores ranged from 3.7 to 12.0 (very easy to difficult) for the VFQ-25 and 2.2 to 12.0 (very easy to difficult) for the SF-36v2. Because survey respondents may not comprehend items with readability scores that exceed their reading ability, estimating the readability of each survey item is an important component of evaluating survey readability. Standards for measuring the readability of surveys are needed.

Focus groups: A qualitative method complementing quantitative research for studying culturally diverse groups

CONTEXT Focus groups are becoming an important method for conducting qualitative research in health care. This strategy enables information to be gathered on the perceptions, beliefs, and values of a groups participants and is particularly well suited to addressing cultural characteristics that impact on a populations health status. As nations become more culturally diverse, qualitative research will likely play a growing role in helping health professions educators develop appropriate educational programs and in helping researchers better understand the needs of minorities and other vulnerable populations who are experiencing disparities in health care. OBJECTIVES The purposes of this paper are to introduce the usefulness of a qualitative research strategy as an adjunct to quantitative survey research, and to describe briefly how researchers and educators at the Charles R. Drew University of Medicine and Science (Drew) have utilized this strategy when conducting combined qualitative and quantitative research. DISCUSSION Focus group research has been successfully used to develop culturally adapted surveys, to develop educational programs, and to conduct needs assessments at Drew, which serves a culturally diverse urban population.

A Comparison of Two Educational Methods on Immigrant Latinas Breast Cancer Knowledge and Screening Behaviors

Underutilization of screening mammography by Latinas continues unabated and may contribute to disparities in disease-free survival and mortality. Objective. Comparison of two discussion group-centered educational interventions at enhancing breast cancer knowledge, breast self-exams (BSE), and screening mammography. Methods. Pre-test post-test study design. Two cohorts of 200 Latinas each participated in survey screening and discussion groups at baseline. One cohort also viewed an animated video and had BSE training. Breast cancer knowledge, self-reported BSE and mammography history were measured at baseline and three months post-intervention. Results. Breast cancer knowledge scores were good for both groups at baseline, and significantly increased at three month follow-up for both groups (p<.05) but no significant difference was observed between groups at baseline or post-intervention. Conclusion. Community-based discussion groups are a cost-effective method for improving breast cancer knowledge and promoting screening behaviors.

A Community-Based Pilot Study of a Diabetes Pharmacist Intervention in Latinos: Impact on Weight and Hemoglobin A1c

Type 2 diabetes disproportionately affects Latinos increasing their risk of diabetes-related complications. This study used a randomized controlled design with a community-based approach to evaluate the impact of a culturally tailored pharmacist intervention on clinical outcomes in Latino diabetics. The intervention included a focused discussion and two individual pharmacist counseling sessions on medication, nutrition, exercise, and self-care to promote behavior changes. Sessions were culturally adapted for language, diet, family participation, and cultural beliefs. Clinical outcomes were measured at baseline and three months. Nineteen intervention and 24 control participants completed the study. Mean BMI reduction was greater for intervention than for control group participants (–0.73± 0.07 kg/m2 versus + 0.37±0.02 kg/m2 p<.009 respectively). Hemoglobin A1c was significantly reduced by 0.93±0.45% in the intervention group only. There was no significant difference in blood glucose, blood pressure, or lipid levels. An innovative culturally-sensitive pharmacist intervention improved selected clinical outcomes among Latino diabetics.

Culture and linguistics: neglected variables in the health communication equation.

Disseminating written health information has been the cornerstone of primary and secondary disease prevention efforts aimed at improving the public health. However, in our multicultural society, diverse linguistics and language use and the lack of literacy skills among the majority of Americans hampers health information campaigns. Developing readable documents, creating language translations that are culturally appropriate, and recognizing the limitation that varying literacy skills impose on communicating health information are the 3 main concerns for ensuring an informed public. The provision of documents with very easy readability (linguistic attribute) is arguably the most important of the triad since with it, the 2 others can be factored into a solvable health communication equation. Standard (average) literacy skills are estimated to be at the seventhto eighth-grade level for the general population. This means that the average person will have difficulty deciphering most health information for comprehension since health-related information consistently requires reading skills at high school to graduate school levels, labeled categorically as difficult to very difficult to read. Therefore, there exists a health information–reading comprehension gap for most Americans that is disparate for vulnerable populations who are known to have limited literacy skills. Although linguistically and culturally appropriate health information is mandated by government and health delivery system quality oversight committees, their incorporation into the structure and process of health care has been slow. There is an urgency to develop and provide health information that is usable by different cultural groups since they differ in their explanations for disease and its physical, emotional, and social manifestations. For example, traditional healing practices influence health behaviors. These behaviors are appropriate in the context of a cultural group’s historical, sociocultural, and environmental reality but often contradict Western biomedical evidencebased practices for preventing and treating disease. Importantly, many population groups often use and/or seek traditional care before biomedical care. This is especially important for documented as well as undocumented immigrants and the poor. These population groups may seek biomedical health care only when self-treatment and/or traditional healing practices are unsuccessful or only when illness interferes with their social and family roles. Cultural pluralism, fear of deportation, unemployment, and uninsured status encourage underuse of biomedical services. Late-stage chronic disease presentation is a common result of this phenomenon with its associated poorer health outcomes and increased cost of

Improving Diabetes Health Literacy by Animation.

Purpose and Scope To produce a Spanish/English animated video about diabetes; to qualitatively assess cultural and linguistic appropriateness; and to test effectiveness at improving diabetes health literacy among Latino/Hispanics. Methods Participatory research and animation production methods guided development of the video. Cultural appropriateness was assessed through focused discussion group methods. A prospective randomized controlled trial tested the effectiveness of the Spanish version at improving diabetes health literacy, compared to “easy to read” diabetes information from the National Institute of Diabetes and Digestive and Kidney Diseases. Functional health literacy was measured by the Short Test of Functional Health Literacy in Adults. Diabetes health literacy was measured by the Diabetes Health Literacy Survey (DHLS). Results No significant differences were recorded between experimental (n = 118) and control groups (n = 122) at baseline on demographic characteristics, Short Test of Functional Health Literacy in Adults score, or DHLS score. Fifty-eight percent of the study participants had inadequate functional health literacy. Mean DHLS score for all participants and those having adequate functional health literacy were 0.55 and 0.54, respectively (inadequate diabetes health literacy). When adjusting for baseline DHLS score, sex, age, and insurance status, DHLS scores improved significantly more in the experimental group than the control group (adjusted mean = 55% vs 53%, F = 4.7, df = 1, P = .03). Interaction between experimental group and health literacy level was significant (F = 6.37, df = 2, P = .002), but the experimental effect was significant only for participants with inadequate health literacy (P = .009). Conclusions The positive effect on DHLS scores suggests that animation has great potential for improving diabetes health literacy among Latinos having limited functional health literacy. A study is needed that targets participants with inadequate health literacy and that uses the English and Spanish versions of the video.

Applying an Expanded Set of Cognitive Design Principles to Formatting the Kidney Early Evaluation Program (KEEP) Longitudinal Survey

BACKGROUND The National Kidney Foundation Kidney Early Evaluation Program (KEEP) is a free community-based health-screening program targeting populations at greatest risk of chronic kidney disease (CKD), those with high rates of diabetes and hypertension, and a high proportion of racial/ethnic minorities. The KEEP Longitudinal Survey will adopt methods similar to those used in KEEP to gather follow-up data to measure CKD-related heath status and gauge program effectiveness for repeated KEEP participants with evidence of CKD stages 3 to 5. KEEP has defined objectives to enhance follow-up survey response rates and target vulnerable populations who bear the greatest CKD risk-factor burdens. METHODS The KEEP Follow-up Form was assessed for adherence to 6 cognitive design principles (simplicity, consistency, organization, natural order, clarity, and attractiveness) considered to summate the techniques guiding good survey development and for the additional cognitive design principles of readability and variation of readability across survey items. RESULTS The KEEP Follow-up Form was found to include violations of each cognitive design principle and readability principle, possibly contributing to item nonresponse and low follow-up rates in KEEP. It was revised according to empirically substantiated formatting techniques guided by these principles and found during qualitative assessment to be more user friendly, simpler, better organized, more attractive, and easier to read. Subsequent development of the KEEP Longitudinal Survey form also was guided by these principles. CONCLUSION To ensure ease of use by populations with limited literacy skills, poor health literacy, and limited survey literacy, survey researchers must apply cognitive design principles to survey development to improve participation and response rates.

Case Study of an Unsustainable Community-Academic Partnership: Toward Core Standards for the Structure of Emerging Participatory Research.

This report retrospectively examines the structure of an emerging community-academic participatory research (PR) partnership that was not sustainable, despite attempts to adhere to PR principles and demonstrable success in research outcomes. The influence of community and academic parent organizations on the PR process and outcomes is presented in the context of the Donabedian Model. We dissected the structural elements contributed by parent organizations to forming the structure of the PR partnership (memorandum of understanding, policy environment, human resources and effort, community and academic resources, expertise and experience, and funding) and explored the influence of potential and actual conflicts on the PR partnerships sustainability. The effect of potential and actual conflict on the PR process and quality of PR outcomes is discussed. Based on this, we conclude by proposing seven core standards for the establishment and development of emerging community-academic PR partnerships.