Sarah A. McGraw

Expanding the Andersen Model: The Role of Psychosocial Factors in Long-Term Care Use

OBJECTIVE To examine a prevailing conceptual model of health services use (Andersen 1995) and to suggest modifications that may enhance its explanatory power when applied to empirical studies of race/ethnicity and long-term care. STUDY SETTING Twelve focus groups of African-American (five groups) and white (seven groups) individuals, aged 65 and older, residing in Connecticut during 2000. STUDY DESIGN Using qualitative analysis, data were coded and analyzed in NUD-IST 4 software to facilitate the reporting of recurrent themes, supporting quotations, and links among the themes for developing the conceptual framework. Specific analysis was conducted to assess distinctions in common themes between African-American and white focus groups. DATA COLLECTION Data were collected using a standardized discussion guide, augmented by prompts for clarification. Audio taped sessions were transcribed and independently coded by investigators and crosschecked to enhance coding validity. An audit trail was maintained to document analytic decisions during data analysis and interpretation. PRINCIPAL FINDINGS Psychosocial factors (e.g., attitudes and knowledge, social norms, and perceived control) are identified as determinants of service use, thereby expanding the Andersen model (1995). African-American and white focus group members differed in their reported accessibility of information about long-term care, social norms concerning caregiving expectations and burden, and concerns of privacy and self-determination. CONCLUSIONS More comprehensive identification of psychosocial factors may enhance our understanding of the complex role of race/ethnicity in long-term care use as well as the effectiveness of policies and programs designed to address disparities in long-term care service use among minority and nonminority groups.

What Matters to Older African Americans Facing End-of-Life Decisions? A Focus Group Study

BACKGROUND To better understand what matters to African American elders who are faced with issues of death, dying, and end-of-life care, a qualitative study was conducted to elicit their perspective. METHODS Focus groups were convened across the state of Connecticut. A total of 196 individuals participated in the 90-minute interview sessions. Using an interview guide, a trained moderator conducted the racially homogeneous discussion groups. Transcriptions of the group narratives with 22 older African Americans were coded to identify themes. Data were organized and analyzed using NUD-IST 4 and constant comparative method of qualitative data analysis. RESULTS Five major themes emerged from the focus group data on older African Americans: (1) spirituality, (2) burden on family, (3) trust, (4) health insurance coverage, and (5) cultural concerns. CONCLUSION Recommendations are made for outreach education, involvement of informal helpers, and a level of acceptability in practice for diverse care needs.

Do blacks and whites differ in their use of health care for symptoms of coronary heart disease

OBJECTIVES The purpose of this study was to identify the role of race in seeking and receipt of care for symptoms of coronary heart disease. METHODS Data on medical care, sociodemographic characteristics, symptoms, risk factors, income, and insurance were collected in a telephone interview for a random sample of 2030 Black and White adults in inner-city Boston. Rates of care-seeking for symptoms, amounts of delay in seeking care, and rates of receipt of care were compared for Blacks and Whites after adjustment for other characteristics. RESULTS Before and after adjustment for other factors, Blacks and Whites were equally likely to seek care. Average delay time was shorter for Blacks, particularly Black women. With the exception of a lower rate of referral to cardiologists among Blacks, receipt of care was similar for Blacks and Whites who sought medical attention for symptoms. CONCLUSIONS In an urban population of Blacks and Whites who were similar in socioeconomic status and access to medical care, there were few racial differences in coronary heart disease-related care patterns.

Factors Affecting Cigarette Smoking and Intention to Smoke Among Puerto Rican-American High School Students

Using data from a survey of Puerto Rican adolescents in Boston and Hartford, a cross-sectional analysis was conducted of factors affecting recent cigarette smoking status and intentions to smoke in the next 5 years. Among Puerto Rican-American high school students between the ages of 14 and 20 years, nearly 12% of the males and 10% of the females had smoked at least one cigarette during the month prior to in-home interviews. Two factors -the proportion of close friends who smoked and exposure to smokers during recreational activities-were positively associated with the likelihood that respondents had smoked in the past month and intended to smoke in the future. The smoking status offamily members had no major independent effects on a teens behavior. Degree of acculturation, measured by three language usage items, was associated with higher rates of smoking by male students but not by females. These results suggest that peer pressure is as important an influence on the cigarette smoking behavior of Puerto Ricans as it is for non-Latino students.

HIV risk among Latino adolescents in two New England cities

OBJECTIVES Latino adolescents in two urban New England areas were surveyed to assess risk of human immunodeficiency virus (HIV) transmission. METHODS Probability of HIV infection during the previous 6 months was estimated from self-reported sexual contacts, condom usage rates, and number of partners. Teens were also asked to show condoms in their possession to the interviewer to validate self-reports of condom use. RESULTS Overall, 8% of the 586 respondents were classified as high risk for HIV infection (estimated infection probability greater than .0001), 34% were at moderate risk, and the remaining 58% were classified as not at risk (no sexual activity or needle sharing). Teens who said they had purchased condoms or claimed to have used them recently were more likely than others to have condoms in their possession at the time of the interview. CONCLUSIONS These estimates suggest that a small percentage of Latino adolescents may be at substantial risk for HIV infection over periods as short as 6 months, that self-reports of recent condom use are strongly related to condom possession, and that questionnaire items regarding condom use at last intercourse are poor surrogates for HIV risk.

Smoking Behavior of Puerto Rican Women: Evidence from Caretakers of Adolescents in Two Urban Areas

This study examines cigarette smokingpatterns amongPuertoRican women responsible for caring for adolescents in two metropolitan areas in the Northeastern United States. The age-adjusted prevalence of cigarette smoking in the caretaker sample was higher than the rates for all adult women in the 1985 National Health Interview Survey and the 1986 Adult Use of Tobacco Survey. Smoking prevalence among the caretakers was very similar to the rate reported byPuertoRican women in theNew York City area interviewed during the Hispanic Health and Nutrition Examination Survey. Logistic regression analysis indicated that educational attainment, religious affiliation and marital status influenced the probability that a caretaker currently smokeL Acculturation had a modest positive effect on current smoking. Puerto Rican women may be an important target group for smoking cessation programs because quit rates among ever smokers are still comparatively low and because many of these women are light smokers.

Help-seeking behaviors of blacks and whites dying from coronary heart disease

Objectives : This study sought to determine whether blacks and whites with life-threatening cardiac events differ in likelihood of help seeking, types of help sought, or likelihood of reaching the hospital before death. Design : Death certificates were used to identify all coronary heart disease-related deaths occurring in 1988-89 among 45- to 74-year-old, black and white, non-institutionalized residents of three contiguous inner-city districts in Boston, Massachusetts, USA. An informant was interviewed about the decedents health status, access to care and pre-mortal help-seeking behaviors. Results : Among the 232 decedents analyzed, there were no racial differences in the likelihood of help seeking. Among those who sought help, there were no racial differences in the likelihood of reaching the hospital. However, blacks were more likely than whites to engage in two specific help-seeking behaviors: calling the 911 emergency system, and trying to reach an emergency room. Conclusion : In an area where blacks and whites were similar with respect to socioeconomic status and access to care, race did not affect the likelihood of help seeking or the likelihood of succeeding in reaching the hospital before death.

A focus group study of DES daughters: implications for health care providers.

A focus group study of women exposed to diethylstilbestrol (DES) in utero (DES daughters) was conducted to gain understanding about exposure to this drug from a patient perspective. Focus group participants reported that learning about their DES exposure was devastating; they experienced strains in their family relationships, emotional shock, a feeling that their health concerns were not appreciated by others and, to some degree, a sense of social isolation. Although many were aware of the need for special gynecological exams and high‐risk prenatal care, they were frustrated by what they felt was a lack of reliable and clear information about the effects of DES exposure. Most expressed questions and anxiety about their health. Many found their communication with physicians about their DES exposure unsatisfying. They felt that physicians lacked information about the long‐term health effects of DES exposure and as a result did not give them accurate information. Furthermore, they felt that physicians were dismissive of their concerns and often gave what they felt to be false reassurances. Consequently, the women developed an enduring distrust of the medical profession. The results of the study suggest implications for the delivery of health care to DES daughters. Copyright

Exposure to Diethylstilbestrol: Design of a Multilevel Community Intervention

The planning of community health education interventions aimed at multiple levels is complex and challenging. This challenge is increased when a primary audience is difficult to reach. Individuals who were exposed to diethylstilbestrol (DES) decades ago represent a difficult-to-reach audience because they are not always aware of their exposure or the health risks of their exposure. However, DES-exposed individuals need specific screening and health care. An intervention was developed to increase awareness about DES in Nassau County, New York to address this concern. The Precede-Proceed Model was used to develop distinct intervention strategies to reach the general public, which includes individuals who may not be aware that they were exposed; those who are aware of their exposure but may not be following recommended health care practices; and community physicians. Behavioral targets, determining factors, and intervention goals were identified for each group. Specific intervention strategies were planned and implemented for each target audience. Addressing three target audiences simultaneously may produce a synergistic effect, enhancing program impact.