Physician-community health worker partnering to support diabetes self-management in primary care.

BACKGROUND: The role of community health workers (CHWs) has expanded from outreach and education to working within a clinical team in a primary care setting. AIM: To improve self-management among patients with type 2 diabetes incorporating CHWs as members of a clinical team. METHODS: A cohort of 114 patients with type 2 diabetes enrolled in 2007 participated in a teambased self-management intervention with followup in 2008. The study assessed whether significant changes occurred in clinical, patient satisfaction and activation measures after the intervention compared with baseline. The programme was located at St Luke's Health Care Center in San Francisco, California, in an ethnically diverse neighbourhood serving predominantly low-income Latino patients. Clinical outcomes measured included glycosylated haemoglobin (HbA1c), low-density lipoprotein (LDL), blood pressure and total cholesterol. A Patient Activation Measure (PAM) assessed self-management. Both provider and patient experiences with the programme were also assessed using a patient telephone satisfaction survey and provider focus group. RESULTS: The majority of patients were Latino Spanish speaking women on public insurance. Thirty-one patients participated in a telephone satisfaction survey. Six providers participated in a focus group to assess satisfaction with care. HealthFirst had a positive impact, improving HbA1c among high-risk patients with type 2 diabetes (HbA1c≥ 9.0) and maintaining glycaemic control among patients with controlled glycaemic level at baseline (HbA1c<7.0). In addition, LDL, total cholesterol and self-management outcomes significantly improved. Ninety-seven percent of patients were satisfied with the CHWs' support. Overall, providers' comfort level in referring patients to CHWs was very high. CONCLUSIONS: Physician-CHW partnership had a positive impact on patients' self-management skills and clinical outcomes. Patients and physicians also had higher satisfaction with overall care. With appropriate training, CHWs can collaborate as team members with primary care providers and with non-medical providers to improve the quality of care.

Assessing dual-role staff-interpreter linguistic competency in an integrated healthcare system.

BACKGROUND: Interpreter services for medical care increase physician-patient communication and safety, yet a "formal certification" process to demonstrate interpreter competence does not exist. Testing and training is left to individual health care facilities nationwide. Bilingual staff are often used to interpret, without any assessment of their skills. Assessing interpreters' linguistic competence and setting standards for testing is a priority. OBJECTIVE: To assess dual-role staff interpreter linguistic competence in an integrated health care system to determine skill qualification to work as medical interpreters. DESIGN: Dual-role staff interpreters voluntarily completed a linguistic competency assessment using a test developed by a language school to measure comprehension, completeness, and vocabulary through written and oral assessment in English and the second language. Pass levels were predetermined by school as not passing, basic (limited ability to read, write, and speak English and the second language) and medical interpreter level. Five staff-interpreter focus groups discussed experiences as interpreters and with language test. RESULTS: A total of 840 dual-role staff interpreters were tested for Spanish (75%), Chinese (12%), and Russian (5%) language competence. Most dual-role interpreters serve as administrative assistants (39%), medical assistants (27%), and clinical staff (17%). Two percent did not pass, 21% passed at basic level, 77% passed at medical interpreter level. Staff that passed at the basic level was prone to interpretation errors, including omissions and word confusion. Focus groups revealed acceptance of exam process and feelings of increased validation in interpreter role. CONCLUSIONS: We found that about 1 in 5 dual-role staff interpreters at a large health care organization had insufficient bilingual skills to serve as interpreters in a medical encounter. Health care organizations that depend on dual-role staff interpreters should consider assessing staff English and second language skills.

Ethnic differences in decisional balance and stages of mammography adoption.

Behavioral theories developed through research with mainstream, English-speaking populations have been applied to ethnically diverse and underserved communities in the effort to eliminate disparities in early breast cancer detection. This study tests the validity of the transtheoretical model (TTM) decisional balance measure and the application of the TTM stages of change in a multiethnic, multilingual sample. A random sample of 1,463 Filipino, Latino, African American, Chinese, and White women aged 40 to 74 completed a phone survey of mammography beliefs and practices. Consistent with the TTM and independent of ethnicity, decisional balance was associated with mammography stage in all five ethnic groups when controlling for socioeconomic and other factors. In addition, having private insurance and a regular physician and being a long-time resident in the United States were positively associated with mammography maintenance. The application of the TTM for mammography is supported in a multiethnic and multilingual sample.

Timely follow-up among multicultural women with abnormal mammograms.

OBJECTIVE: To examine factors influencing time from screening to final diagnosis among multicultural women with abnormal mammograms using the precede-proceed model. METHODS: Staff of 58 clinics and a sample of 436 women served by these clinics were interviewed and their medical records examined. RESULTS: Longer duration from screening to diagnosis was associated with speaking Spanish and having clinic staff make appointments. Ease of access to health care, provision of early morning screening services and higher levels of patient anxiety shortened the time to diagnosis. CONCLUSION: The precede-proceed model is useful in delineating personal and structural factors that affect timely diagnosis.

Patient and clinical site factors associated with rescreening behavior among older multiethnic, low-income women.

PURPOSE: Our goal was to identify factors predictive of mammography rescreening within 18 months of baseline screening in multiethnic, low-income older women. DESIGN AND METHODS: We interviewed a cross-sectional survey of staff of 102 randomly selected clinics that provided screening and diagnostic services. We also surveyed a random sample of 391 older women served by these clinics to retrospectively assess their experiences of the screening process. RESULTS: We found that 59% of the sample returned for a repeat mammogram. Education level and the belief it is important to get an annual mammogram were significant patient-level predictors of rescreening. Offering pap smears and using hands-on demonstrations with breast models were significant clinic-level variables predictive of rescreening. Of note, among the variables that did not prove significant in the final model were those reflecting ethnicity and income. IMPLICATIONS: Individual and health-care-delivery-system factors play important roles in the obtaining of regular mammograms by low-income women. These findings highlight the importance of both factors in improving rescreening rates among older women.

Access and attitudinal factors related to breast and cervical cancer rescreening: why are Latinas still underscreened?

To identify access, attitudes, and health practices of Latina women undergoing regular mammography and Pap smear screening, 977 Latinas aged 40 to 74, residing in four California cities, answered a telephone interview. Forty-one percent of women had regular mammography, and 73% had regular Pap smear screening. Cancer screening maintenance was associated with having health insurance, a regular place of care, and fewer fatalistic attitudes about cancer. Regular mammography and Pap smear screening were also associated with ever being married, attending church, and having taken hormone replacement therapy. Being older than 50, residing in the United States a long time, and having had a hysterectomy predicted mammography maintenance. Pap smear screening maintenance was negatively associated with poverty, old age, and negative attitudes toward physicians. There are structural and attitudinal barriers to regular cancer screening among Latinas. Interventions that increase access to care and address women's attitudes about cancer are needed.

Mammography rescreening among women of diverse ethnicities: patient, provider, and health care system factors.

This study identified patient, provider, and health care system factors that influenced mammography rescreening among non-insured, racial/ethnic minority women. Data were collected using a stratified-clustered random sample survey of 1,050 women of five racial/ethnic groups (Latina, Chinese, Filipina, African American, and Caucasian) and 102 primary care clinical sites. Women received screening services through two no-cost screening programs in California. Chi-square tests were used to assess bivariate associations and multiple logistic regressions were used to compute adjusted odds ratios and 95% confidence intervals. Mammography rescreening was associated with living in the United States longer; having higher education levels, better health care access, a history of breast problems, and favorable perceptions of mammography; obtaining regular Pap screening and hormone replacement therapy; having had better communication with clinicians; and attending clinics that conducted in-reach activities. This study suggests that simply removing financial barriers is not enough to improve mammography rescreening among underserved women.

Mothers' attitudes toward adolescent confidential services: development and validation of scales for use in English- and Spanish-speaking populations.

PURPOSE: To explore parental beliefs and attitudes about confidential services for their teenagers; and to develop an instrument to assess these beliefs and attitudes that could be used among English and Spanish speakers. The long-term goal is to use this research to better understand and evaluate interventions to improve parental knowledge and attitudes toward their adolescent's access and utilization of comprehensive confidential health services. METHODS: The instrument was developed using an extensive literature review and theoretical framework followed by qualitative data from focus groups and in-depth interviews. It was then pilot tested with a random sample of English- and Spanish-speaking parents and further revised. The final instrument was administered to a random sample of 1,000 mothers. The psychometric properties of the instrument were assessed for Spanish and English speakers. RESULTS: The instrument consisted of 12 scales. Most Cronbach alphas were >.70 for Spanish and English speakers. Fewer items for Spanish speakers "loaded" for the Responsibility and Communication scales. Parental Control of Health Information failed for Spanish speakers. CONCLUSIONS: The Parental Attitudes of Adolescent Confidential Health Services Questionnaire (PAACS-Q) contains 12 scales and is a valid and reliable instrument to assess parental knowledge and attitudes toward confidential health services for adolescents among English speakers and all but one scale was applicable for Spanish speakers. More research is needed to understand key constructs with Spanish speakers.

Understanding the attitudes of Latino parents toward confidential health services for teens.

OBJECTIVES: To explore the knowledge and attitudes that Latino parents have about confidential health services for their teens and to identify factors that may influence those attitudes. METHODS: Latino parents of teens (12-17 years) were randomly selected from a large health maintenance organization and a community-based hospital to participate in 1-hour focus groups. We conducted eight focus groups in the parent's preferred language. Spanish and English transcripts were translated and coded with intercoder reliability >80%. RESULTS: There were 52 participants (30 mothers, 22 fathers). There is a wide range of parental knowledge and attitudes about confidential health services for teens. Parents believed they had the right to know about their teens' health but were uncomfortable discussing sexual topics and thought confidential teen-clinician discussions would be helpful. Factors that influence parental acceptability of confidential health services include parental trust in the clinician; the clinician's interpersonal skills, clinical competencies, and ability to partner with parents and teens; and clinician-teen gender concordance. Most parents preferred teens' access to confidential services than having their teens forego needed care. CONCLUSIONS: This study identifies several underlying issues that may influence Latino youths' access to confidential health services. Implications for clinical application and future research are discussed.

Collecting patient race/ethnicity and primary language data in ambulatory care settings: a case study in methodology.

OBJECTIVE: To collect patient race/ethnicity and language (r/e/l) in an ambulatory care setting. DATA SOURCES/STUDY SETTING: The Palo Alto Medical Foundation (PAMF), December 2006-May 2008. STUDY DESIGN: Three pilot studies: (1) Comparing mail versus telephone versus clinic visit questionnaire distribution; (2) comparing the front desk method (FDM) versus exam room method (ERM) in the clinic visit; and (3) determining resource allocation necessary for data entry. DATA COLLECTION/EXTRACTION METHODS: Studies were planned and executed by PAMF's Quality and Planning division. PRINCIPAL FINDINGS: Collecting r/e/l data during clinic visits elicited the highest response rate. The FDM yielded higher response rate than the ERM. One full-time equivalent is initially necessary for data entry. CONCLUSIONS: Conducting sequential studies can help guide r/e/l collection in a short time frame.

Intention, subjective norms, and cancer screening in the context of relational culture.

Research targeting disparities in breast cancer detection has mainly utilized theories that do not account for social context and culture. Most mammography promotion studies have used a conceptual framework centered in the cognitive constructs of intention (commonly regarded as the most important determinant of screening behavior), self-efficacy, perceived benefit, perceived susceptibility, and/or subjective norms. The meaning and applicability of these constructs in diverse communities are unknown. The purpose of this study is to inductively explore the social context of Filipina and Latina women (the sociocultural forces that shape people's day-to-day experiences and that directly and indirectly affect health and behavior) to better understand mammography screening behavior. One powerful aspect of social context that emerged from the findings was relational culture, the processes of interdependence and interconnectedness among individuals and groups and the prioritization of these connections above virtually all else. The authors examine the appropriateness of subjective norms and intentions in the context of relational culture and identify inconsistencies that suggest varied meanings from those intended by behavioral theorists.

Behavioral theory in a diverse society: like a compass on Mars.

The behavioral theory constructs most often used to study mammography utilization-perceived benefit, perceived susceptibility, self-efficacy, intention, and subjective norms-have neither been developed nor sufficiently tested among diverse racial/ethnic subgroups. The authors explored these constructs and their underlying assumptions relating to the social context of Filipina and Latina women. The mixed-methods study included testing construct measures in the multilingual surveys of a concurrent intervention study of 1,463 women from five ethnic groups. An intensive inductive investigation then targeted Latina and Filipina women to elucidate connections between social context and individual screening behavior. In-depth interviews were conducted with 11 key informant scholars, 13 community gatekeepers, and 29 lay women, and a supplemental study videotaped and interviewed 9 mother-daughter dyads. Three social context domains emerged: relational culture, social capital, and transculturation and transmigration. The meaning and appropriateness of the five behavioral constructs were analyzed in relation to these domains. In contradistinction to tenets of behavioral theory, the authors found that social context can influence behavior directly, circumventing or attenuating the influence of individual beliefs; contextual influences, synthesized from multiple perspectives, can operate at an unconscious level not accessible to the individual; and contextual influences are dynamic, contingent on distal and proximal forces coming together in a given moment and are thus not consistent with an exclusive focus at the individual level. This article describes the study methods, summarizes main findings, and preview the detailed results presented in the other articles in this issue.

Improving rescreening in community clinics: does a system approach work?

Community clinics provide inadequate breast cancer screening services to low-income, racially- and ethnically-diverse communities. This study develops and evaluates the effectiveness of multifaceted organizational system interventions--operational assessments, tracking systems, reminder calls, tailored education, physician prompts and a tailored counseling call--on mammography rescreening rates within three community clinics. We used the Chronic Care Model and Put Prevention Into Practice framework to redesign breast screening delivery services within the California Cancer Detection Programs: Every Woman Counts (CDP:EWC), community clinic settings. We used a quasi-experimental design with a random selection of 400 patients at pre-intervention. To establish a post-intervention clinic's rescreening rate a new comparable cross-sectional random sample of 347 women was drawn. Measures A chart abstraction instrument was used to establish clinics' rescreening rates. Subjects participants at pre and post-intervention were low-income women 50 years of age and older who had received normal mammography results and had not been diagnosed with breast cancer in the last five years. General linear mixed model analysis revealed significant improvements for the organizational system redesign condition [pre-intervention rescreening rate: 32.1 percent v. post-intervention rescreening rate 50.2 percent, (p < .001)]. For the organizational system redesign plus tailored counseling call condition, there was maintenance in the rescreening rate following the intervention [pre-intervention: 44.4 percent v. post-intervention: 45.1 percent, (p > 0.05)]. Multilevel interventions directed at redesigning community clinics primary care breast cancer screening services, can improve mammography rescreening rates.

The effectiveness of a community outreach intervention to improve follow-up among underserved women at highest risk for cervical cancer.

BACKGROUND: A disproportionate number of women diagnosed with cervical cancer are from low-income and/or ethnically diverse groups. This study was designed to evaluate the effectiveness of an outreach and counseling intervention at improving the rate of follow-up of abnormal Pap smears among women at Alameda County Medical Center, Oakland, CA. METHODS: Between September 1, 1999 and August 31, 2001, 348 women with abnormal Pap test results were randomly assigned to intervention or usual care. The main outcome was rate of follow-up. RESULTS: The intervention produced a significant increase in the rate of follow-up visits within 6 months. Women in the intervention group were much more likely to obtain timely follow-up at Highland Hospital than were those in the control group (61% vs. 32%, P = 0.001). The intervention was equally effective when delivered to women in the control group who had no follow-up by 6 months. Overall, we were able to contact 90% of women in the intervention group. CONCLUSIONS: An outreach intervention is highly effective at increasing follow-up of abnormal Pap smears in a public hospital setting. Institutions offering cervical cancer screening to low-income, high-risk women should consider the use of outreach workers to reduce loss to follow-up.

Increasing ethnic diversity in cancer control research: description and impact of a model training program.

BACKGROUND: There is little ethnic diversity at the doctoral level among researchers in cancer control. The Minority Training Program in Cancer Control Research is designed to encourage underrepresented master's level health science students to pursue doctoral training and careers in research. METHODS: Program components include an annual 5-day summer institute, internships, and doctoral incentive awards. Intention to pursue doctoral training is measured before and after participation. Doctoral applications and enrollment are tracked through annual surveys. RESULTS: Seventy students participated during the first three years, 1999-2001. Intention to apply increased significantly for each class (year one, p %lt; 0.001; year two, p = 0.042; year three, p = 0.006). Thirty-one percent of participants have either enrolled in doctoral programs (n= 10) or report plans to apply in the next one to two years (n = 9). Over half of these students indicated that the MTPCCR had a positive influence on their plans. CONCLUSIONS: A targeted training program encourages under-represented students to pursue doctoral degrees and thus has the potential to increase ethnic diversity in public health research.