Geographic disparities associated with travel to medical care and attendance in programs to prevent/manage chronic illness among middle-aged and older adults in Texas.

INTRODUCTION: Accessing care is challenging for adults with chronic conditions. The challenge may be intensified for individuals needing to travel long distances to receive medical care. Transportation difficulties are associated with poor medication adherence and delayed or missed care. This study investigated the relationship between those traveling greater distances for medical care and their utilization of programs to prevent and/or manage their health problems. It was hypothesized that those traveling longer distances for medical care attended greater chronic disease management programs. METHODS: Thirty six thousand households in nine counties of central Texas received an invitation letter to participate in a mailed health assessment survey in English or Spanish. A total of 5230 participants agreed to participate and returned the fully completed survey. To investigate distance traveled for medical services and participation in a chronic disease management program, the analyses were limited to 2108 adults aged ≥51 years with one or more chronic conditions who visited a healthcare professional at least once in the previous year. Other variables of interest included residential rurality, health status, and personal characteristics. The data were first analyzed using descriptive and bivariate analyses. Then, an ordinal logistic regression model was fitted to identify factors associated with longer distances traveled to medical services. Additionally, a binary logistic regression model was fitted to identify factors associated with attending a chronic disease self-management program. RESULTS: Among 2108 adults, rural participants (p<0.001), those with more chronic conditions (p<0.001), and those attending a chronic disease program (p=0.037) reported traveling further distances to medical services. Participants with limited activity (p<0.001), those from urban counties (p=0.017), and those who traveled further (p=0.030) were more likely to attend a chronic disease program. CONCLUSION: While further distances to healthcare providers was found to be a protective factor based on the utilization of community-based resources, rural residents were less likely to attend a program to better manage their chronic conditions, potentially choosing to use long distance travel to address urgent medical needs rather than focusing on prevention and management of their conditions. Important policy and programmatic efforts are needed to increase reach of chronic disease self-management programs and other community services and resources in rural areas and to reduce rural inequities.

The Benefits and Challenges of Managing Asthma in Hispanic Families in South Texas: A Mixed-Methods Study.

BACKGROUND: Understanding the experience of Hispanic parents of children diagnosed with asthma can be useful in the delivery of effective and meaningful asthma education. In order to assess the needs of Hispanic families with asthmatic children in South Texas, investigators utilized a combination of qualitative and quantitative research methods. OBJECTIVES: This study aimed (1) to assess the impact of asthma in the quality of life of Hispanic children and their families and (2) to identify barriers and challenges to asthma management as perceived by parents of children diagnosed with asthma. METHODS: A mixed-methods study included a quality-of-life survey and focus group discussions. The Children's Health Survey for Asthma (CHSA) was completed by 90 parents of children with asthma. Three focus groups were conducted with 15 low-income, Hispanic parents of asthmatic children to assess their needs and experience in managing the disease. RESULTS: Results from the CHSA showed that asthma significantly affects the quality of life of children with asthma and their families, particularly the emotional dimensions and the child's physical health. Fifty-three percent of the children had visited the emergency room, and 51% had been hospitalized due to asthma. One out of five parents had missed work, and 27% of children had missed school in the past 2 weeks due to the child's asthma. In the focus group discussions, the key themes emerging included lack of asthma knowledge, the burden of disease for asthmatic children and their families, and the importance of asthma education and self-management behaviors for asthma control. CONCLUSION: One of the main challenges faced by Hispanic families with asthmatic children is the lack of asthma-related knowledge to help understand and control their children's disease. Lack of knowledge and self-management skills lead to significant stress and anxiety among children with asthma and their parents. Results highlight that while asthma has an effect on the quality of life of children and their families, particularly on the emotional health domain, a wide dissemination of asthma management education in different settings might help prevent asthma attacks and improve symptom control among those suffering from this disease along the US-Mexico border.

Diabetes Screening and Prevention in a High-Risk, Medically Isolated Border Community.

INTRODUCTION: A project in a Texas border community setting, Prevention Organized against Diabetes and Dialysis with Education and Resources (POD2ER), offered diabetes prevention information, screening, and medical referrals. The setting was a large, longstanding flea market that functions as a shopping mall for low-income people. The priority population included medically underserved urban and rural Mexican Americans. Components of the program addressed those with diabetes, prediabetes, and accompanying relatives and friends. BACKGROUND: People living in the Lower Rio Grande Valley (LRGV) face challenges of high rates of type 2 diabetes, lack of knowledge about prevention, and inadequate access to medical care. Recent statistics from actual community-wide screenings indicate a high diabetes prevalence, 30.7% among adults in the LRGV compared with 12.3% nationwide. METHODS: A diverse team composed of public health faculty, students, a physician, a community health worker, and community volunteers conceived and developed the project with a focus on cultural and economic congruence and a user-friendly atmosphere. The program provided screening for prediabetes and diabetes with a hemoglobin A1c test. Screening was offered to those who were at least 25 years of age and not pregnant. When results indicated diabetes, a test for kidney damage was offered (urinary albumin-to-creatinine ratio). A medical appointment at a community clinic within a week was provided to those who tested positive for diabetes and lacked a medical home. Health education modules addressed all family members. DISCUSSION: The project was successful in recruiting 2,332 high-risk people in 26 months in a community setting, providing clinic referrals to those without a doctor, introducing them to treatment, and providing diabetes prevention information to all project participants. Implications for research and practice are highlighted. CONCLUSION: This study shows that a regular access point in a place frequented by large numbers of medically marginalized people in a program designed to eliminate cultural and economic barriers can succeed in providing a hard-to-reach community with diabetes prevention services. Aspects of this program can serve as a model for other service provision for similar populations and settings.

Relative Association of Multi-Level Supportive Environments on Poor Health among Older Adults.

Background: The aging of the United States population poses significant challenges to American healthcare and informal caregiving systems. Additional research is needed to understand how health promotion programs and policies based on a socio-ecological perspective impact the health and well-being of older persons. The purpose of this study was to investigate personal characteristics and supportive environments associated with poor health among older individuals aged 65 and over. Methods: This study used a cross-sectional design and was guided by a conceptual framework developed by the authors to depict the relationship between personal characteristics and environments associated with poor health status. Environment types included in this study were family, home, financial, neighborhood, and healthcare. The sample was comprised of 1319 adults aged 65 years and older residing in Central Texas. From a random selection of households, participants were administered a mail-based survey created by a community collaborative effort. Descriptive statistics and three binary logistic regression models were fitted to examine associations with poor health status (i.e., physical, mental, and combined physical/mental). Results: Two personal characteristics (number of chronic conditions and educational level) were consistently related (p < 0.05) to health outcomes. Supportive family, home, financial, neighborhood, and health care environmental factors were shown to be related (p < 0.05) to various aspects of physical or mental health outcomes. Conclusions: Multidimensional factors including personal characteristics and protective environments are related to health status among older individuals. The unique roles of each environment can help inform public health interventions to create and enhance support for older adults to engage in healthful activities and improve their physical and mental health.

Does injury prevention education initiate household changes in a Spanish-speaking minority population?

Young children from low income families are among the most affected population of unintentional injury. This non-randomized longitudinal study examined knowledge for home and child safety with an injury prevention training offered to parents of children who reside in the Rio Grande Valley of Texas. Eighty eight parents received the training and pre-and post-test surveys were used to measure knowledge outcomes. A follow-up survey was conducted 2 months after the educational intervention to identify how many parents reported household and safety behavior changes as a result of the training. The most significant change in behavior, as it pertains to the household, was related to locking and storage of dangerous cleaning chemicals. Other significant changes in behavior were in areas that directly related to the child such as learning how to swim, use of sun block and fire safety in the home. This study suggests that tailored trainings can improve parent knowledge and change in behaviors for the promotion of safety activities to avoid risks for unintentional injuries. Further, the study identified certain at-risk areas that need to be addressed from an educational perspective. These areas include bicycle and water safety; specifically, the use of protective gear when bicycling; understanding and adhering to traffic rules when bicycling; and, the dangers of drowning in small quantities of water.

Mexican-American children's perspectives: neighborhood characteristics and physical activity in Texas-Mexico border colonias.

The qualitative study described in this article investigated perceptions about environmental factors influencing physical activity (PA) among children from underserved neighborhoods known as colonias in the U.S.-Mexico border. Ten focus groups were conducted with 67 Mexican-American colonia children ages 8 to 13 living in one of the poorest border counties in the U.S. Analyses indicated that PA among children was influenced by neighborhood characteristics, including litter, speeding cars, unleashed dogs, and dark streets. The children also underlined intrapersonal and social environmental factors. Findings may inform policy makers and public health professionals about ways to promote PA among underserved children through urban planning and programs focusing on PA-supportive infrastructure, neighborhood safety, and family- and home-based physical activities.

Bridging research and policy to address childhood obesity among border Hispanics: a pilot study.

BACKGROUND: Mexican-American children are disproportionately affected by obesity compared to other population groups. Although national guidelines recommend using environmental and policy approaches to address this public health issue, the majority of Mexican-American children do not meet physical activity recommendations. PURPOSE: To describe a knowledge transfer process involving local decision makers to address childhood obesity and physical activity needs among low-income, Mexican-American children and to examine environmental policy recommendations generated in this process. METHODS: This pilot study employed a qualitative research design that included the dissemination of primary research data to local decision makers in the Texas-Mexico border region. Stakeholders attending public meetings were briefed about a research project reporting on the physical activity needs of Mexican-American children from impoverished neighborhoods known as colonias. Seventy-four stakeholders responded to an unstructured questionnaire and proposed policy recommendations. Data were collected January-April 2011 and analyzed July-September 2011. Data were analyzed using a content analysis technique. RESULTS: Four policy themes emerged from the data: (1) establishing sustainable community-based health programs; (2) improving neighborhood infrastructure and safety; (3) increasing access to parks; and (4) supporting community organizations to disseminate health education to parents and children. CONCLUSIONS: Knowledge transfer processes planned and facilitated by researchers at public meetings with local decision makers are effective methods to influence policy development related to childhood obesity.

Role and working conditions of nurses in public health in Mexico and Peru: a binational qualitative study.

AIM: This exploratory study conducted in Mexico and Peru investigated nurses' perceptions about their role in public health and working conditions. BACKGROUND: Health reform efforts in many countries are redefining the role of health professionals in public health. Little is known about the role of nurses working in public health contexts in Latin America. METHOD: Fourteen focus groups were conducted in Mexico and Peru with 82 nurses working in government-sponsored community health centres. Data were analysed using a content analysis technique. FINDINGS: Themes identified were: nurses' job descriptions in public health settings; organisational factors influencing the nurses' work, and influence of academic and social image factors. CONCLUSION: Management barriers and limited training influences the role and working conditions of public health nurses in Mexico and Peru. IMPLICATIONS FOR NURSING MANAGEMENT: The professional role of nurses working in public health in Latin America is not well defined because of the health-care system infrastructure and the lack of a clear public health nurse job description. Further research is needed to better understand the role of public health nurses and strengthen their training, particularly in relation to nursing management encompassing abilities for decision-making processes and public health program planning and evaluation.

The impact of asthma health education for parents of children attending head start centers.

Parents of children who attend Head Start Centers are key participants in the health promotion and care of their own children. This non-randomized, longitudinal study aimed to test the effectiveness of an educational intervention based on the asthma and healthy homes curriculum targeting parents of Head Start children with or without an asthma diagnosis. One hundred and fifteen parents of children in Head Start Centers received an educational intervention at their corresponding sites, additionally pre- and post-test surveys were administered to measure educational intervention outcomes. A follow-up survey was conducted 6 months after the educational intervention was offered. Results showed a statistically significant increase in asthma and healthy home-knowledge (p < 0.001) in several areas. At 6 months post-intervention (54.4 %) (61 participants) were contacted and 98.4 % of made changes in their households as a result of their training. This study suggests that education can improve knowledge and change behaviors for the well-being of the residents of that household.

Personal and cultural influences on diabetes self-care behaviors among older Hispanics born in the U.S. and Mexico.

Older Hispanics are disproportionately affected by diabetes, but little is known about predictors of diabetes self-care among this group. This study compared the magnitude of three self-care behaviors (diet, physical activity (PA), and glucose monitoring) among older Hispanics with type 2 diabetes born in the United States (n = 59) to those born in Mexico (n = 179), and investigated the influence of personal and health indicators on each self-care behavior. Findings were based on data drawn from convenience sample data collected with a questionnaire. Self-care behaviors were moderately practiced (39.5-45.8 %) with no significant differences by nativity. Mexico-born seniors were less linguistically acculturated (P < 0.001). Being female (OR = 2.41) and PA levels (OR = 2.62) were significantly associated with diet. Being female (OR = 3.24), more educated (OR = 3.73), U.S.-born (OR = 2.84), and receiving diabetes education (OR = 3.67) were associated with PA. Diabetes education (OR = 2.41) was associated with glucose monitoring. Although acculturation influenced only PA and no other behaviors, personal and cultural factors require further investigation to design diabetes management strategies for Hispanic seniors at the border region.

Factors influencing health care utilization in older Hispanics with diabetes along the Texas-Mexico border.

Little is known about predictors of health care utilization for older Hispanics with chronic conditions. This study aimed to determine: (1) the level of health care access for older Hispanics with type 2 diabetes living in a US-Mexico border area; and (2) personal and health correlates to health care utilization (ie, physician visits, eye care, emergency room [ER] use). This was a cross-sectional study based on a community assessment conducted at a clinic, senior centers, and colonias. Colonias are impoverished neighborhoods with substandard living conditions along the US-Mexico border. Hispanics living in colonias are one of the most disadvantaged minority groups in the United States. The study sample consisted of 249 Hispanics age 60 years and older who have type 2 diabetes. Descriptive analyses, multiple linear regression, and generalized linear models were conducted. Older age (P = 0.02) and affordability of physician fees (P = 0.02) were significant correlates to more frequent physician visits. Factors significantly associated with eye care were being insured (P = 0.001) and reporting high cholesterol (P = 0.005). ER use was significantly associated with younger age (60-64 years old; P = 0.03) and suffering from hypertension (P = 0.02). Those who received diabetes education (P = 0.04) were less likely to use the ER. Identifying patterns of health care utilization services in aging underserved minorities who are disproportionately affected by diabetes may lead to culturally appropriate preventive practices and timely access to health care. Adequate health care access can decrease or delay the onset of diabetes complications in older Hispanics with type 2 diabetes who live along the US-Mexico border.

Incorporating what promotoras learn: becoming role models to effect positive change.

Promotoras (community health workers) play an important health promotion role and must be continuously trained, but little is known about how much of their learning they actually put into practice. This non-randomized, longitudinal study examined knowledge and home environmental outcomes of an asthma and healthy homes training offered to promotoras using a train-the-trainer model. Eighty-five promotoras received the training and pre- and post-test surveys were used to measure training outcomes. Results showed a statistically significant increase in asthma and healthy home-related knowledge (P < .001). At 12-months post-intervention, a majority of the promotoras (69%) reported they made household changes to improve their indoor environment as a result of the training. This study suggests that effective trainings can improve promotoras knowledge and behaviors for the promotion of healthy homes in the community. Further evaluation is needed to investigate whether these trainings allow promotoras to serve as role models within their communities "by educating through example" and thereby enhance their credibility as health educators.

A pilot walking program for Mexican-American women living in colonias at the border.

PURPOSE: To test the effectiveness of ¡Vamos a Caminar! (Let's Walk!), an intervention for Mexican-American women living in economically disadvantaged, poorly urbanized areas in the South Texas border region. DESIGN: This was a nonexperimental, one-group, pretest and posttest intervention with a duration of 12 weeks. SETTING: The intervention was conducted in Hidalgo County, Texas, 1 of the 10 poorest counties in the United States, located at the border with Mexico. Participants resided in areas known as colonias, which are unincorporated and impoverished settlements along the border where many people live in trailers or self-built houses and lack basic services. SUBJECTS: Spanish-speaking Mexican-American women (n  =  16) 18 years of age and older. INTERVENTION: The program was home-based, culturally sensitive, theoretically driven, and facilitated by community health workers. MEASURES: Changes in walking levels, depressive symptoms, and stress levels were assessed. ANALYSIS: Descriptive statistics and the Wilcoxon matched-pairs signed-ranks test were used. RESULTS: A majority of participants were unemployed, had low levels of education, were born in Mexico, and were obese. After exposure to the program, the participants reported a significant increase in walking (915.8 metabolic equivalent min/wk; p  =  .002) and lower depressive symptoms (p  =  .055) and stress level scores (p  =  .017). CONCLUSIONS: Culturally sensitive programs promoting walking in underserved, minority populations are promising in reducing physical activity disparities.

Pilot of a diabetes primary prevention program in a hard-to-reach, low-income, immigrant Hispanic population.

An immigrant Hispanic population in the Texas-Mexico border region urgently requested assistance with diabetes. The project team implemented an exploratory pilot intervention to prevent type 2 diabetes in the general population through enhanced nutrition and physical activity. Social networks in low-income rural areas(colonias) participated in an adaptation of the Diabetes Empowerment Education Program. The program had a pre-post-test design with a comparison group. The intervention had a small but significant effect in lowering body mass index, the biological outcome variable. The process evaluation shows that the participants valued the pilot project and found it culturally and economically appropriate. This program was the first primary prevention program in diabetes to address a general population successfully. The study shows that low-income, rural Mexican American families will take ownership of a program that is participatory and tailored to their culture and economic situation.

Personal and social determinants of health services utilization by Mexican older people.

BACKGROUND: Increased healthcare needs among older individuals around the world demands a better understanding of factors influencing healthcare service utilization patterns. OBJECTIVE: To examine personal and social correlates to health services utilization among Mexican older persons. DESIGN AND METHODS: This was a cross-sectional study conducted between 2004 and 2006 with 2030 Mexican adults 60 years and older and based on a health services utilization framework. A two-stage cluster sampling with probability proportionate to size was used. Participants were randomly selected and recruited in four metropolitan areas in Northeastern Mexico. Chi-square and Pearson's chi-squared tests and logistic regression were used for data analyses. RESULTS: Significantly more women than men had lost a spouse and were illiterate. Also, females reported significantly poorer health, higher nutritional risk and lower ability to perform activities of daily and instrumental living than males. Predictors of healthcare utilization were: Having a caregiver during an illness; perceiving to have a health problem; being able to afford food, and having children. CONCLUSIONS: Predisposing, enabling and need factors are strong predictors of health services utilization among Mexican older persons. In addition, gender differences exist among this population in relation to health status, but not to health services demands.

Ethnic and health correlates of diabetes-related amputations at the Texas-Mexico border.

OBJECTIVE: To examine the association between diabetes-related lower-extremity amputation (LEA) and ethnicity, age, source of payment, geographic location, diabetes severity, and health condition in adults with diabetes mellitus type 2 living in border and non-border counties in Texas, United States of America, and to assess intra-border region geographic differences in post-LEA treatment. METHODS: This correlational study was based on secondary data from the 2003 Texas Inpatient Hospital Discharge Data. The sample consisted of individuals 45 years of age and older with type 2 diabetes who had undergone a nontraumatic LEA (n = 5,865). Descriptive statistics and logistic regression analyses were applied. RESULTS: The following characteristics were predictors of LEA: being Hispanic or African American, male, ≥ 55 years old, and a Medicare or Medicaid user, and living in a border county. Persons with moderate diabetes and those who suffered from cardiovascular disease or stroke also had higher odds of undergoing an LEA. Post-LEA occupational therapy was significantly less prevalent among border residents (9.5%) than non-border residents (15.3%) (P < 0.001). CONCLUSION: Understanding the factors that influence diabetes-related LEA may lead to early detection and effective treatment of this disabling consequence of diabetes along the U.S.-Mexico border.

Ethnic and health correlates of diabetes-related amputations at the Texas-Mexico border / Correlatos étnicos y de salud de las amputaciones relacionadas con la diabetes en la frontera entre Texas y México

OBJECTIVE: To examine the association between diabetes-related lower-extremity amputation (LEA) and ethnicity, age, source of payment, geographic location, diabetes severity, and health condition in adults with diabetes mellitus type 2 living in border and non-border counties in Texas, United States of America, and to assess intra-border region geographic differences in post-LEA treatment. METHODS: This correlational study was based on secondary data from the 2003 Texas Inpatient Hospital Discharge Data. The sample consisted of individuals 45 years of age and older with type 2 diabetes who had undergone a nontraumatic LEA (n = 5 865). Descriptive statistics and logistic regression analyses were applied. RESULTS: The following characteristics were predictors of LEA: being Hispanic or African American, male, > 55 years old, and a Medicare or Medicaid user, and living in a border county. Persons with moderate diabetes and those who suffered from cardiovascular disease or stroke also had higher odds of undergoing an LEA. Post-LEA occupational therapy was significantly less prevalent among border residents (9.5 percent) than non-border residents (15.3 percent) (P < 0.001). CONCLUSION: Understanding the factors that influence diabetes-related LEA may lead to early detection and effective treatment of this disabling consequence of diabetes along the U.S.-Mexico border.

OBJETIVO: Analizar la asociación entre las amputaciones de extremidades inferiores (AEI) relacionadas con la diabetes y el grupo étnico, la edad, la procedencia del pago, la ubicación geográfica, la gravedad de la diabetes y el estado de salud de los adultos que padecen diabetes tipo 2 residentes en los condados fronterizos y no fronterizos de Texas (Estados Unidos de América), y evaluar la diferencias geográficas dentro de la zona fronteriza en cuanto al tratamiento posterior a la amputación. MÉTODOS: Este estudio correlacional se basó en datos secundarios procedentes de la información de egreso de pacientes hospitalizados en Texas durante el año 2003. La muestra estuvo integrada por personas de 45 años o mayores con diabetes tipo 2, que habían sido sometidas a la amputación no traumática de una extremidad inferior (n = 5 865). Se aplicaron estadística descriptiva y análisis de regresión logística. RESULTADOS: Las siguientes características constituyeron factores predictivos de AEI: ser hispano o afroestadounidense, hombre, de 55 años o mayor, beneficiario de Medicare o Medicaid, y residente en un condado fronterizo. Las personas con diabetes moderada que padecían enfermedades cardiovasculares o habían sufrido un accidente cerebrovascular también tenían una mayor probabilidad de ser sometidas a una AEI. La terapia ocupacional posterior a la amputación fue significativamente menos prevalente entre los residentes fronterizos (9,5 por ciento) que entre los no fronterizos (15,3 por ciento) (P < 0,001). CONCLUSIONES: La comprensión de los factores que influyen en las AEI relacionadas con la diabetes puede conducir a la detección temprana y el tratamiento eficaz de esta secuela discapacitante en la zona fronteriza entre los Estados Unidos y México.

The science of sustaining health behavior change: the health maintenance consortium.

OBJECTIVE: To enhance understanding of the long-term maintenance of behavior change, as well as effective strategies for achieving sustainable health promotion and disease prevention through the Health Maintenance Consortium (HMC). METHODS: This introductory research synthesis prepared by the resource center gives context to this theme issue by providing an overview of the HMC and the articles in this journal. RESULTS: It explores the contributions to our conceptualization of behavior change processes and intervention strategies, the trajectory of effectiveness of behavioral and social interventions, and factors influencing the long-term maintenance of behavioral and social interventions. CONCLUSIONS: Future directions for furthering the science of maintaining behavior change and reducing the gaps between research and practice are recommended.

A qualitative case study examining intervention tailoring for minorities.

OBJECTIVES: To explore issues of intervention tailoring for ethnic minorities based on information and experiences shared by researchers affiliated with the Health Maintenance Consortium (HMC). METHODS: A qualitative case study methodology was used with the administration of a survey (n = 17 principal investigators) and follow-up telephone interviews. Descriptive and content analyses were conducted, and a synthesis of the findings was developed. RESULTS: A majority of the HMC projects used individual tailoring strategies regardless of the ethnic background of participants. Follow-up interview findings indicated that key considerations in the process of intervention tailoring for minorities included formative research; individually oriented adaptations; and intervention components that were congruent with participants' demographics, cultural norms, and social context. CONCLUSIONS: Future research should examine the extent to which culturally tailoring long-term maintenance interventions for ethnic minorities is efficacious and should be pursued as an effective methodology to reduce health disparities.

Anatomy of culturally sensitive interventions promoting nutrition and exercise in hispanics: a critical examination of existing literature.

Compared with non-Hispanic Whites, Hispanics experience a disproportionate burden of chronic diseases. Understanding the factors influencing the success of health programs in Hispanics requires a clearer examination of the principles and components of tailored interventions. This research comprises a comprehensive literature review of randomized controlled trials testing nutrition and exercise interventions tailored for Hispanics and an examination of how these interventions were constructed. The review of 18 interventions meeting study criteria suggests that most tailored programs promoting nutrition and exercise in Hispanics are theory driven and are informed by formative research. Also, the findings indicate that salient culturally sensitive intervention components are (a) bilingual and bicultural facilitators and materials, (b) family-based activities, (c) literacy-appropriate materials, and (d) social support. A clear understanding of Hispanic cultural values is also required. Further empirical examination is warranted to determine the factors mediating or predicting the efficacy of culturally sensitive health programs for Hispanics.