Health inequities and the inappropriate use of race in nephrology.

Chronic kidney disease is an important clinical condition beset with racial and ethnic disparities that are associated with social inequities. Many medical schools and health centres across the USA have raised concerns about the use of race - a socio-political construct that mediates the effect of structural racism - as a fixed, measurable biological variable in the assessment of kidney disease. We discuss the role of race and racism in medicine and outline many of the concerns that have been raised by the medical and social justice communities regarding the use of race in estimated glomerular filtration rate equations, including its relationship with structural racism and racial inequities. Although race can be used to identify populations who experience racism and subsequent differential treatment, ignoring the biological and social heterogeneity within any racial group and inferring innate individual-level attributes is methodologically flawed. Therefore, although more accurate measures for estimating kidney function are under investigation, we support the use of biomarkers for determining estimated glomerular filtration rate without adjustments for race. Clinicians have a duty to recognize and elucidate the nuances of racism and its effects on health and disease. Otherwise, we risk perpetuating historical racist concepts in medicine that exacerbate health inequities and impact marginalized patient populations.

A Novel Curriculum for Medical Student Training in LGBTQ Healthcare: A Regional Pathway Experience.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals face considerable health disparities, often due to a lack of LGBTQ-competent care. Such disparities and lack of access to informed care are even more staggering in rural settings. As the state medical school for the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region, the University of Washington School of Medicine (UWSOM) is in a unique position to train future physicians to provide healthcare that meets the needs of LGBTQ patients both regionally and nationally. OBJECTIVE: To describe our methodology of developing a student-driven longitudinal, region-wide curriculum to train medical students to provide high-quality care to LGBTQ patients. METHODS: A 4-year LGBTQ Health Pathway was developed and implemented as a student-led initiative at the UWSOM. First- and second-year medical students at sites across the WWAMI region are eligible to apply. Accepted Pathway students complete a diverse set of pre-clinical and clinical components: online modules, didactic courses, longitudinal community service/advocacy work, a scholarly project, and a novel clinical clerkship in LGBTQ health developed specifically for this Pathway experience. Students who complete all requirements receive a certification of Pathway completion. This is incorporated into the Medical Student Performance Evaluation as part of residency applications. RESULTS: The LGBTQ Health Pathway is currently in its fourth year. A total of 43 total students have enrolled, of whom 37.3% are based in the WWAMI region outside of Seattle. Pathway students have completed a variety of scholarly projects on LGBTQ topics, and over 1000 hours of community service/advocacy. The first cohort of 8 students graduated with a certificate of Pathway completion in spring 2020. CONCLUSIONS: The LGBTQ Health Pathway at UWSOM is a novel education program for motivated medical students across the 5-state WWAMI region. The diverse milestones, longitudinal nature of the program, focus on rural communities, and opportunities for student leadership are all strengths and unique aspects of this program. The Pathway curriculum and methodology described here serve as a model for student involvement and leadership in medical education. This program enables medical students to enhance their training in the care of LGBTQ patients and provides a unique educational opportunity for future physicians who strive to better serve LGBTQ populations.

Increased Prevalence of Psychosocial, Behavioral, and Socio-Environmental Risk Factors among Overweight and Obese Youths in Mexico and the United States.

The aim of this study was to examine various psychosocial, behavioral, and socio-environmental factors in a multiethnic sample of healthy-weight, overweight, and obese youths in the United States (US) and Mexico and determine differences by sex. We conducted a cross-sectional analysis of 633 youths aged 11-18 years who completed a self-reported questionnaire. Height and weight were measured to determine body mass index (BMI). Overweight and obese youth in both countries were significantly more likely to report a higher body image dissatisfaction (Odds Ratio (OR) = 1.67 and OR= 2.95, respectively), depressive symptoms (OR = 1.08 and OR = 1.12, respectively), perceive themselves as overweight (OR = 2.57) or obese (OR = 5.30), and a lower weight-specific quality of life (OR = 0.97 and OR = 0.95, respectively) than healthy-weight youth. Obese youth have lower healthy lifestyle priorities (OR = 0.75) and are less likely to be physically active (OR = 0.79) and eat breakfast (OR = 0.47) than healthy-weight youth. Additionally, overweight and obese youth are more likely to engage in weight control behaviors (OR = 5.19 and OR = 8.88, respectively) and restrained eating than healthy-weight youth. All the aforementioned results had a p-value of <0.05, which was considered statistically significant. The association between these factors and overweight or obesity remained significant after controlling for age, sex, race/ethnicity, and country. In conclusion, obesity was associated with a range of psychosocial, behavioral, and socio-environmental risk factors in both countries. Our findings support the need for multifactorial approaches when developing interventions to address the growing problem of obesity among youth in the US and Mexico.

Racial/Ethnic Disparities in Clinical Grading in Medical School.

Phenomenon: Performance during the clinical phase of medical school is associated with membership in the Alpha Omega Alpha Honor Medical Society, competitiveness for highly selective residency specialties, and career advancement. Although race/ethnicity has been found to be associated with clinical grades during medical school, it remains unclear whether other factors such as performance on standardized tests account for racial/ethnic differences in clinical grades. Identifying the root causes of grading disparities during the clinical phase of medical school is important because of its long-term impacts on the career advancement of students of color. Approach: To evaluate the association between race/ethnicity and clinical grading, we examined Medical Student Performance Evaluation (MSPE) summary words (Outstanding, Excellent, Very Good, Good) and 3rd-year clerkship grades among medical students at the University of Washington School of Medicine. The analysis included data from July 2010 to June 2015. Medical students were categorized as White, underrepresented minorities (URM), and non-URM minorities. Associations between MSPE summary words and clerkship grades with race/ethnicity were assessed using ordinal logistic regression models. Findings: Students who identified as White or female, students who were younger in age, and students with higher United States Medical Licensing Examination Step 1 scores or final clerkship written exam scores consistently received higher final clerkship grades. Non-URM minority students were more likely than White students (Adjusted Odds Ratio = 0.53), confidence interval [0.36, 0.76], p = .001, to receive a lower category MSPE summary word in analyses adjusting for student demographics (age, gender, maternal education), year, and United States Medical Licensing Examination Step 1 scores. Similarly, in four of six required clerkships, grading disparities (p < .05) were found to favor White students over either URM or non-URM minority students. In all analyses, after accounting for all available confounding variables, grading disparities favored White students. Insights: This single institution study is among the first to document racial/ethnic disparities in MSPE summary words and clerkship grades while accounting for clinical clerkship final written examinations. A national focus on grading disparities in medical school is needed to understand the scope of this problem and to identify causes and possible remedies.

A Digital Language Divide? The Relationship between Internet Medication Refills and Medication Adherence among Limited English Proficient (LEP) Patients.

BACKGROUND: Use of an Internet portal to refill medicines positively affects medication adherence among English-speakers. No prior studies, however, have specifically examined the relationship between Internet refills and medication adherence among patients who are limited English proficient (LEP). OBJECTIVES: (1) Examine the relationship between Internet medication refill system use and medication adherence among linguistically diverse patients with chronic conditions and (2) compare this relationship between LEP and English-proficient (EP) patients. DESIGN, PARTICIPANTS, MEASURES: We analyzed 2013-2014 cross-sectional data from 509 surveyed adults in the Group Health Cooperative. Surveys were merged with plan enrollment, claims data, and electronic medical records. Medication adherence was calculated by the "Continuous Measure of Medication Gaps" (CMG) method. For Internet refill system use, patients were asked, "Have you used the health systems Internet site to refill any medications in the last 12 months?" LEP status was captured in the electronic medical record by a non-English primary language and a claims record of interpreter use in at least one clinical encounter between 2005 and 2012. We used multivariate linear regression models to examine Internet refill system use and medication adherence and compared the association between LEP and EP patients. RESULTS: Three hundred eighty-four patients (75%) had a calculable CMG: 134 EP and 250 LEP in the adherence analyses. In unadjusted analyses, LEP patients had lower use of the Internet refill system (p < .001) and lower adherence versus the EP group (p < .001). In multivariate analyses, LEP status (ß = - 0.022, p = .047) was negatively associated with adherence, while use of the Internet refill system (ß = 0.030, p = .002) was positively associated. In stratified models, use of Internet refills was positively associated with adherence, even when examining LEP (ß = 0.029, p = .003) and EP patients (ß = 0.027, p = .049) separately. CONCLUSIONS: These findings suggest that LEP patients may be under-utilizing a beneficial Internet tool. Should our healthcare systems fail to ensure that LEP patients have full and meaningful access to Internet patient portals, we risk worsening healthcare disparities.

Migration, Health Care Behaviors, and Primary Care for Rural Latinos with Diabetes.

Many US Latinos migrate or travel between the US and Mexico on a regular basis, defined as circular migration. Latinos with diabetes (n = 250) were surveyed about circular migration and their ability to use medications and perform recommended diabetes self-care activities. A review of medical charts was performed. Twenty-eight percent (n = 70) of patients traveled to Mexico during the last 12 months. Older Latinos were more likely to report traveling to Mexico and back into the US. Among those that traveled, 29 % reported use of less medication than they wanted to or were prescribed because of travel and 20 % ran out of medications. The rate of reported problem areas while traveling were 39 % (27/70) for following a diabetic diet, 31 % (21/70) for taking medication, and 37 % (26/70) for glucose self-monitoring. The results suggest that the structure of primary care and care coordination are important for this population to fully engage in diabetes self-care.

Disparities in the Use of Internet and Telephone Medication Refills among Linguistically Diverse Patients.

BACKGROUND: Health systems are increasingly implementing remote telephone and Internet refill systems to enhance patient access to medication refills. Remote refill systems may provide an effective approach for improving medication non-adherence, but more research is needed among patients with limited English proficiency with poor access to remote refill systems. OBJECTIVE: To compare the use of remote medication refill systems among limited-English-proficiency (LEP) and English-proficient (EP) patients with chronic conditions. METHODS: Cross-sectional survey in six languages/dialects (English, Cantonese, Mandarin, Korean, Vietnamese, and Spanish) of 509 adults with diabetes, hypertension, or hyperlipidemia. Primary study outcomes were self-reported use of 1) Internet refills, 2) telephone refills, and 3) any remote refill system. LEP was measured by patient self-identification of a primary language other than English and a claims record of use of an interpreter. Other measures were age, gender, education, years in the U.S., insurance, health status, chronic conditions, and number of prescribed medications. Analyses included multivariable logistic regression weighted for survey non-response. RESULTS: Overall, 33.1 % of patients refilled their medications by telephone and 31.6 % by Internet. Among LEP patients (n = 328), 31.5 % refilled by telephone and 21.2 % by Internet, compared with 36.7 % by telephone and 52.7 % by Internet among EP patients (n = 181). Internet refill by language groups were as follows: English (52.7 %), Cantonese (34.9 %), Mandarin (17.4 %), Korean (16.7 %), Vietnamese (24.4 %), and Spanish (12.6 %). Compared to EP patients, LEP patients had lower use of any remote refill system (adjusted odds ratio [AOR] 0.18; p < 0.001), CONCLUSIONS: LEP patients are significantly less likely than EP patients to use any remote medication refill system. Increased reliance on current systems for remote medication refills may increase disparities in health outcomes affecting LEP patients with poor access to telephone and Internet medication refills.

Latinos with diabetes and food insecurity in an agricultural community.

BACKGROUND: Latinos from agricultural communities have a high prevalence of food insecurity and are at increased risk of obesity and diabetes, yet little is known about the associations between food insecurity and diabetes outcomes. OBJECTIVE: To examine the associations between food insecurity and diabetes outcomes among rural Latinos. METHODS: Cross-sectional survey with medical chart abstraction of 250 Latinos with diabetes. Primary outcomes are the control of 3 intermediate diabetes outcomes (hemoglobin A1C ≤8.0%, LDL-cholesterol ≤100 mg/dL, and blood pressure ≤140/90 mm Hg), a composite of control of the 3, and receipt of 6 processes of care. Secondary outcomes are cost-related medication underuse and participation in self-care activities. RESULTS: Fifty-two percent of patients reported food insecurity and 1-in-4 reported cost-related medication underuse. Patients with food insecurity were more likely to report cost-related medication underuse [adjusted odds ratio (AOR)=2.49; 95% confidence intervals (CI), 1.30, 4.98; P=0.003], less likely to meet the composite measure for control of the 3 intermediate outcomes (AOR=0.24; 95% CI, 0.07, 0.84; P<0.05), and less likely to receive a dilated eye examination (AOR=0.37; 95% CI, 0.18, 0.77; P<0.05) and annual foot examinations (AOR=0.42; 95% CI, 0.20, 0.84; P<0.05) compared with those who were food secure. CONCLUSIONS: Among this rural Latino population, food insecurity was independently associated with not having control of the intermediate diabetes outcomes captured in the composite measure, not receiving dilated eye and foot examinations, and with self-reporting cost-related medication underuse.

Evaluation of the Patient-Reported Outcomes Information System (PROMIS(®)) Spanish-language physical functioning items.

PURPOSE: To evaluate the equivalence of the PROMIS(®) physical functioning item bank by language of administration (English versus Spanish). METHODS: The PROMIS(®) wave 1 English-language physical functioning bank consists of 124 items, and 114 of these were translated into Spanish. ANALYSIS: Item frequencies, means and standard deviations, item-scale correlations, and internal consistency reliability were calculated. The IRT assumption of unidimensionality was evaluated by fitting a single-factor confirmatory factor analytic model. IRT threshold and discrimination parameters were estimated using Samejima's Graded Response Model. DIF by language of administration was evaluated. RESULTS: Item means ranged from 2.53 (SD = 1.36) to 4.62 (SD = 0.82). Coefficient alpha was 0.99, and item-rest correlations ranged from 0.41 to 0.89. A one-factor model fits the data well (CFI = 0.971, TLI = 0.970, and RMSEA = 0.052). The slope parameters ranged from 0.45 ("Are you able to run 10 miles?") to 4.50 ("Are you able to put on a shirt or blouse?"). The threshold parameters ranged from -1.92 ("How much do physical health problems now limit your usual physical activities (such as walking or climbing stairs)?") to 6.06 ("Are you able to run 10 miles?"). Fifty of the 114 items were flagged for DIF based on an R(2) of 0.02 or above criterion. The expected total score was higher for Spanish- than English-language respondents. CONCLUSIONS: English- and Spanish-speaking subjects with the same level of underlying physical function responded differently to 50 of 114 items. This study has important implications in the study of physical functioning among diverse populations.

Predictors of 1-year change in patient activation in older adults with diabetes mellitus and heart disease.

OBJECTIVES: To identify patterns and predictors of 1-year change in patient activation in chronically ill older adults. DESIGN: Prospective cohort study. SETTING: Integrated healthcare delivery system. PARTICIPANTS: Members of an integrated delivery system from 2007 to 2009 in western Washington state aged 65 and older with diabetes mellitus or heart disease; participants responded to baseline and 1-year follow-up mailed surveys about their health and health care (N = 2,341). MEASUREMENTS: Patient activation was measured using the 13-item Patient Activation Measure (PAM) at baseline and follow-up. Automated diagnoses and procedure data were extracted from databases. Multinomial logistic regression, stratified according to baseline activation stage, was used to estimate the odds ratios for increasing or decreasing activation stage associated with participant characteristics and serious adverse health events. RESULTS: Fifty-two percent of participants changed activation stage between baseline and follow-up. Of people who changed stage, 54% increased, and 46% decreased. Older age and worse baseline self-reported health were independent predictors of activation change in multivariate models. Changes in health status or serious adverse health events such as the occurrence of hospitalizations, new major diagnoses, or procedures were not related to changes in activation in this age group. CONCLUSION: Patient activation, as measured using the PAM, changes over time in elderly adults with chronic diseases. Clinicians and researchers who use the PAM for patient care or as an outcome measure in research studies should be aware of its fluctuation over time in chronically ill older persons.

Patient-reported quality of pain treatment and use of interpreters in spanish-speaking patients hospitalized for obstetric and gynecological care.

BACKGROUND: Assessment and treatment of pain are based largely on patient's self reports. Patients with limited English proficiency (LEP) may have difficulties communicating their pain symptoms in the presence of language barriers. OBJECTIVE: To determine whether interpreter use was associated with quality of acute pain treatment among Latina patients with limited English proficiency. DESIGN: Secondary analysis of two cross-sectional surveys. PARTICIPANTS: One hundred and eighty-five Latino female patients hospitalized for obstetric and gynecological care who required interpreter services. Patients were classified into two groups according to interpreter availability ('Always' and 'Not Always' available). MAIN MEASURES: Quality of pain treatment was measured by patient report of 1) overall level of pain control during hospitalization; 2) timeliness of pain treatment; and 3) perceived provider helpfulness to treat pain. KEY RESULTS: Patients who always received interpreters were more likely to report higher levels of pain control (P=0.02), timely pain treatment (P=0.02), and greater perceived provider helpfulness to treat their pain (P=0.005), compared with patients who not always received interpreters. CONCLUSION: Use of interpreters by LEP patients was associated with better patient reports on quality of pain treatment, and may also improve clinical interactions related to pain.

Differential item functioning by survey language among older Hispanics enrolled in Medicare managed care: a new method for anchor item selection.

OBJECTIVE: To propose a permutation-based approach of anchor item detection and evaluate differential item functioning (DIF) related to language of administration (English vs. Spanish) for 9 questions assessing patients' perceptions of their providers from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Medicare 2.0 survey. METHOD AND STUDY DESIGN: CAHPS 2.0 health plan survey data collected from 703 Hispanics who completed the survey in Spanish were matched on personal characteristics to 703 Hispanics that completed the survey in English. Steps to be followed for the detection of anchor items using the permutation tests are proposed and these tests in conjunction with item response theory were used for the identification of anchor items and DIF detection. RESULTS: Of the questions studied, 4 were selected as anchor items and 3 of the remaining questions were found to have DIF (P < 0.05). The 3 questions with DIF asked about seeing the doctor within 15 minutes of the appointment time, respect for what patients had to say, and provider spending enough time with patients. CONCLUSIONS: Failure to account for language differences in CAHPS survey items may result in misleading conclusions about disparities in health care experiences between Spanish and English speakers. Statistical adjustments are needed when using the items with DIF.

A comparison of item response theory-based methods for examining differential item functioning in object naming test by language of assessment among older Latinos.

Object naming tests are commonly included in neuropsychological test batteries. Differential item functioning (DIF) in these tests due to cultural and language differences may compromise the validity of cognitive measures in diverse populations. We evaluated 26 object naming items for DIF due to Spanish and English language translations among Latinos (n=1,159), mean age of 70.5 years old (Standard Deviation (SD)±7.2), using the following four item response theory-based approaches: Mplus/Multiple Indicator, Multiple Causes (Mplus/MIMIC; Muthén & Muthén, 1998-2011), Item Response Theory Likelihood Ratio Differential Item Functioning (IRTLRDIF/MULTILOG; Thissen, 1991, 2001), difwithpar/Parscale (Crane, Gibbons, Jolley, & van Belle, 2006; Muraki & Bock, 2003), and Differential Functioning of Items and Tests/MULTILOG (DFIT/MULTILOG; Flowers, Oshima, & Raju, 1999; Thissen, 1991). Overall, there was moderate to near perfect agreement across methods. Fourteen items were found to exhibit DIF and 5 items observed consistently across all methods, which were more likely to be answered correctly by individuals tested in Spanish after controlling for overall ability.

The vulnerability of middle-aged and older adults in a multiethnic, low-income area: contributions of age, ethnicity, and health insurance.

This community-partnered study was developed and fielded in partnership with key community stakeholders and describes age- and race-related variation in delays in care and preventive service utilization between middle-aged and older adults living in South Los Angeles. The survey sample included adults aged 50 and older who self-identified as African American or Latino and lived in ZIP codes of South Los Angeles (N=708). Dependent variables were self-reported delays in care and use of preventive services. Insured participants aged 50 to 64 were more likely to report any delay in care (adjusted predicted percentage (APP)=18%, 95% confidence interval (CI)=14-23) and problems obtaining needed medical care (APP=15%, 95% CI=12-20) than those aged 65 and older. Uninsured participants aged 50 to 64 reported even greater delays in care (APP=45%, 95% CI=33-56) and problems obtaining needed medical (APP=33%, 95% CI=22-45) and specialty care (APP=26%, 95% CI=16-39) than those aged 65 and older. Participants aged 50 to 64 were generally less likely to receive preventive services, including influenza and pneumococcal vaccines and colonoscopy than older participants, but women were more likely to receive mammograms. Participants aged 50 to 64 had more problems obtaining recommended preventive care and faced more delays in care than those aged 65 and older, particularly if they were uninsured. Providing insurance coverage for this group may improve access to preventive care and promote wellness.

Self-reported use of eye care among Latinos: the Los Angeles Latino Eye Study.

PURPOSE: To identify the prevalence and determinants of self-reported eye care use in Latinos. DESIGN: Population-based ocular epidemiologic study in Latinos aged 40+ years living in La Puente, California. PARTICIPANTS: A total of 5455 participants. METHODS: Univariate, multivariable, and stepwise logistic regression analyses were conducted to identify predisposing, enabling, and need variables associated with self-reported eye care use. MAIN OUTCOME MEASURES: Prevalence of self-reported use: eye care visit, having had a dilated examination in the past 12 months, ever having had a dilated examination, and odds ratios for factors associated with self-reported use. RESULTS: Overall, 36% of participants reported an eye care visit and 19% reported having a dilated examination in the past year. Fifty-seven percent reported ever having had a dilated eye examination. Greater eye care use was associated with older age, female gender, bilingual language proficiency (English and Spanish), more education, having health insurance, having a usual place for care, having a regular provider of care, a greater number of comorbidities, visual impairment, and lower vision-specific quality of life scores. CONCLUSIONS: Multiple modifiable factors are associated with greater use and access to eye care for Latinos. Modification of these factors should be a priority because visual impairment has significant impacts on well-being and mortality.

Impact of interpreters on the receipt of new prescription medication information among Spanish-speaking Latinos.

BACKGROUND: For Latinos, limited English proficiency (LEP) is a barrier to receiving important information about a new medication prescription. Access to interpreters may impact the receipt of important medication-related information. OBJECTIVE: To examine the association between interpreter use and reports of new prescription medication advice among Latinos with LEP. METHODS: We examined cross-sectional survey data from 1590 Latino adults with LEP from 8 sites across the United States. The main outcomes are 5 measures of new prescription medication advising: (1) explanation of medication purpose, (2) explanation of possible side effects, (3) explanation of medication directions, (4) receipt of written information in Spanish from pharmacy, and (5) receipt of medicine bottle with Spanish language label. RESULTS: Among patients prescribed a new medication, 72% reported being told about the purpose of the medication, 52% about possible side effects, and 70% about how to take the new medicine. Forty-four percent said they received written medication information in Spanish from pharmacy, and 47% said their medicine bottle label was written in Spanish. Interpreter use was independently associated with receiving explanations about: possible side effects (adjusted odds ratio [AOR] = 1.81; 95% confidence intervals [CI]: 1.16-2.45); medication directions (AOR = 2.50; 95% CI: 1.67-3.59); and medication purpose (AOR = 3.55; 95% CI: 2.14-4.65). CONCLUSIONS: Among Latinos with LEP, interpreter use increases patient receipt of important information when a new medication is prescribed. There is a continuing need for effective policies and interventions to improve provider communication with LEP patients.

Do socioeconomic gradients in subclinical atherosclerosis vary according to acculturation level? Analyses of Mexican-Americans in the multi-ethnic study of atherosclerosis.

OBJECTIVE: To examine whether the association between socioeconomic position (SEP) and subclinical atherosclerosis in Mexican-Americans would be moderated by acculturation. Although SEP shows a consistent, inverse relationship with cardiovascular disease (CVD) risk in westernized non-Hispanic white populations, the relationship in ethnic minorities, including Hispanics, is often weak or even reversed (i.e., worse health with higher SEP). METHODS: Participants were 801 Hispanics of Mexican origin (49.6% = female; average age = 60.47 years) from the Multi-Ethnic Study of Atherosclerosis cohort who underwent computed tomography of the chest for coronary artery calcium (CAC) and thoracic aortic calcium (TAC). SEP was represented by a composite of self-reported education and income. Acculturation was a composite score, including language spoken at home, generation, and years of "exposure" to U.S. culture. RESULTS: Small but statistically significant SEP by acculturation interaction effects were identified in relation to prevalent CAC, prevalent TAC, and extent of TAC (all p < .05). Follow-up analyses revealed that the direction of the SEP gradient on detectable CAC changed as individuals progressed from low to high acculturation. Specifically, the association between SEP and calcification was positive at low levels of acculturation (i.e., a "reversed" gradient), and negative in circumstances of high acculturation (i.e., the expected, protective effect of higher SEP). CONCLUSIONS: The findings support the utility of examining SEP and acculturation simultaneously, and of disaggregating large ethnic groupings (e.g., "Hispanic") into meaningful subgroups to better understand health risks.

Language access services for Latinos with limited English proficiency: lessons learned from Hablamos Juntos.

BACKGROUND: The Robert Wood Johnson Foundation funded Hablamos Juntos (HJ), a $10-million multiyear demonstration to improve access to health care for Latinos with limited English proficiency and to explore cost-effective ways for health care organizations to provide language access services. HABLAMOS JUNTOS: In this manuscript, the authors draw on their experiences in evaluating HJ, provide brief descriptions of innovative interventions, estimate operating costs, and synthesize lessons learned about implementation. A number of barriers and facilitators are documented. CONCLUSION: The experience of HJ grantees provides guidance for organizations contemplating similar efforts. In particular, it highlights the need for health care organizations to involve physicians in the design and adoption of language services.

Adolescent participation in preventive health behaviors, physical activity, and nutrition: differences across immigrant generations for Asians and Latinos compared with Whites.

OBJECTIVES: We investigated preventive health behaviors (bicycle helmet, seat belt, and sunscreen use), physical activity, television viewing or video game playing, and nutrition (fruit, vegetable, milk, and soda consumption) among Asian and Latino adolescents living in the United States; assessed trends across generations (first-, second-, and third-generation immigrants or later); and compared each generation with White adolescents. METHODS: We used data from 5801 adolescents aged 12 to 17 years in the representative 2001 California Health Interview Survey. RESULTS: In multivariate analysis, first-generation Asians measured worse than Whites for preventive health behaviors (lower participation), physical activity (less activity), and television viewing or video game playing (more hours), but improved across generations. For these same behaviors, Latinos were similar to or worse than Whites, and generally showed no improvement across generations. First-generation Asians and Latinos had healthier diets than Whites (higher fruit and vegetable consumption, lower soda consumption). With succeeding generations, Asians' fruit, vegetable, and soda consumption remained stable, but Latinos' fruit and vegetable consumption decreased and their soda consumption increased, so that by the third generation Latinos' nutrition was poorer than Whites'. CONCLUSIONS: For the health behaviors we examined, Asian adolescents' health behaviors either improved with each generation or remained better than that of Whites. Latino adolescents demonstrated generally worse preventive health behaviors than did Whites and, in the case of nutrition, a worsening across generations. Targeted interventions may be needed to address behavioral disparities.

The impact of interpreters on parents' experiences with ambulatory care for their children.

Health plan members who did not need an interpreter in the past 6 months were compared with those who needed one and always, usually, sometimes, or never got one. In multivariate analyses, Hispanic and Asian/Pacific Islanders (API) members who needed interpreters and usually, sometimes, or never used one reported significantly worse (p < .05) provider and office staff communication, access to care, and health plan customer service compared with members who did not need interpreters. Hispanic and API members who needed and always used an interpreter reported similar or significantly better (p < .05) provider and office staff communication, access to care, and health plan customer service than members that did not need interpreters. Use of interpreters reduced White-Hispanic disparities in reports of care by up to 28 percent and White-API disparities by as much as 21 percent. Increasing use of interpreters could reduce racial/ethnic disparities and improve health plan performance.