Validating a Hazardous Drinking Index in a Sample of Sexual Minority Women: Reliability, Validity, and Predictive Accuracy.

BACKGROUND: Although sexual minority women (SMW) are at increased risk of hazardous drinking (HD), efforts to validate HD measures have yet to focus on this population. OBJECTIVES: Validation of a 13-item Hazardous Drinking Index (HDI) in a large sample of SMW. METHODS: Data were from 700 adult SMW (age 18-82) enrolled in the Chicago Health and Life Experiences of Women study. Criterion measures included counts of depressive symptoms and post-traumatic stress disorder (PTSD) symptoms, average daily and 30-day ethanol consumption, risky sexual behavior, and Diagnostic and Statistical Manual (DSM-IV) measures of alcohol abuse/dependence. Analyses included assessment of internal consistency, construction of receiver operating characteristic (ROC) curves to predict alcohol abuse/dependence, and correlations between HDI and criterion measures. We compared the psychometric properties (diagnostic accuracy and correlates of hazardous drinking) of the HDI to the commonly used CAGE instrument. RESULTS: KR-20 reliability for the HDI was 0.80, compared to 0.74 for the CAGE. Predictive accuracy, as measured by the area under the receiver operating characteristic curve for alcohol abuse/dependence, was HDI: 0.89; CAGE: 0.84. The HDI evidenced the best predictive efficacy and tradeoff between sensitivity and specificity. Results supported the concurrent validity of the HDI measure. CONCLUSIONS: The Hazardous Drinking Index is a reliable and valid measure of hazardous drinking for sexual minority women.

Developing Items to Measure Theory of Planned Behavior Constructs for Opioid Administration for Children: Pilot Testing.

The Theory of Planned Behavior (TpB) is useful to direct nursing research aimed at behavior change. As proposed in the TpB, individuals' attitudes, perceived norms, and perceived behavior control predict their intentions to perform a behavior and subsequently predict their actual performance of the behavior. Our purpose was to apply Fishbein and Ajzen's guidelines to begin development of a valid and reliable instrument for pediatric nurses' attitudes, perceived norms, perceived behavior control, and intentions to administer PRN opioid analgesics when hospitalized children self-report moderate to severe pain. Following Fishbein and Ajzen's directions, we were able to define the behavior of interest and specify the research population, formulate items for direct measures, elicit salient beliefs shared by our target population and formulate items for indirect measures, and prepare and test our questionnaire. For the pilot testing of internal consistency of measurement items, Cronbach alphas were between 0.60 and 0.90 for all constructs. Test-retest reliability correlations ranged from 0.63 to 0.90. Following Fishbein and Ajzen's guidelines was a feasible and organized approach for instrument development. In these early stages, we demonstrated good reliability for most subscales, showing promise for the instrument and its use in pain management research. Better understanding of the TpB constructs will facilitate the development of interventions targeted toward nurses' attitudes, perceived norms, and/or perceived behavior control to ultimately improve their pain behaviors toward reducing pain for vulnerable children.

Coming out in color: racial/ethnic differences in the relationship between level of sexual identity disclosure and depression among lesbians.

Disclosing one's sexual minority identity, or "coming out," has varying effects on the mental health of lesbians. Previous research indicates a negative association between disclosure and depression. However, these findings are based on research with White lesbians. To date, there is a paucity of studies that examined how the relationship between disclosure and depression may differ by race/ethnicity among lesbians. To address this gap, we examined the relationship between disclosure and depression among African American (26.5%), Latina (19.7%), and White (53.8%) self-identified lesbians (N = 351) in 2 survey-interviews (∼ 3-years apart). Over 50% of the participants reported a history of lifetime depression at baseline and 35.9% reported depression at Time 2 (T2). Disclosure levels varied: 78.9% had disclosed to their mother, 58.4% to their father, and 83.3% to a sibling. The mean level for disclosure to nonfamily individuals was 6.29 (SD 2.64; range 0-9). Disclosure results varied by race/ethnicity showing African American lesbians (vs. White lesbians) were less likely to disclose to nonfamily individuals when controlling for covariates. Results for the relationship between disclosure and depression showed disclosure to either parent or sibling was not associated with depression for the total sample. Among Latinas only, disclosure to nonfamily individuals was associated with less depression. Additional research is needed to explore racial/ethnic differences in disclosure with certain individuals and to better understand the relation between disclosure and depression. Findings have implications for reducing overall rates of depression among lesbians living with multiple-minority identities.

A longitudinal study of the correlates of persistent smoking among sexual minority women.

INTRODUCTION: We conducted a longitudinal evaluation of factors associated with persistent smoking behaviors among sexual minority women (SMW; lesbians and bisexual women). METHODS: Structured interview data were collected as part of a larger longitudinal study of SMW's health: the Chicago Health and Life Experiences of Women study. We conducted multivariate analyses to evaluate the influence of 4 groups of predictor variables on smoking: (a) demographic, (b) childhood victimization, (c) other substance use, and (d) health variables. RESULTS: At Wave 1, 30.9% (n = 138) of participants reported current smoking, with substance-use and demographic factors having the strongest relationships to smoking status. The majority (84.9%) of Wave 1 smokers were also smoking at Wave 2. Among demographic variables, level of education was inversely associated with continued smoking. With respect to substance use, hazardous drinking and cocaine/heroin use were significantly associated with continued smoking. None of the victimization or health variables predicted smoking status. CONCLUSIONS: Consistent with previous studies, smoking rates in this sample of SMW were elevated. Despite intensive efforts to reduce smoking in the general population, 84% of SMW smokers continued smoking from Wave 1 to Wave 2. Findings suggest that the majority of SMW will continue to smoke over time. Additional research is needed to increase motivation and access to smoking cessation resources.

Comparison of two Bayesian methods to detect mode effects between paper-based and computerized adaptive assessments: a preliminary Monte Carlo study.

BACKGROUND: Computerized adaptive testing (CAT) is being applied to health outcome measures developed as paper-and-pencil (P&P) instruments. Differences in how respondents answer items administered by CAT vs. P&P can increase error in CAT-estimated measures if not identified and corrected. METHOD: Two methods for detecting item-level mode effects are proposed using Bayesian estimation of posterior distributions of item parameters: (1) a modified robust Z (RZ) test, and (2) 95% credible intervals (CrI) for the CAT-P&P difference in item difficulty. A simulation study was conducted under the following conditions: (1) data-generating model (one- vs. two-parameter IRT model); (2) moderate vs. large DIF sizes; (3) percentage of DIF items (10% vs. 30%), and (4) mean difference in θ estimates across modes of 0 vs. 1 logits. This resulted in a total of 16 conditions with 10 generated datasets per condition. RESULTS: Both methods evidenced good to excellent false positive control, with RZ providing better control of false positives and with slightly higher power for CrI, irrespective of measurement model. False positives increased when items were very easy to endorse and when there with mode differences in mean trait level. True positives were predicted by CAT item usage, absolute item difficulty and item discrimination. RZ outperformed CrI, due to better control of false positive DIF. CONCLUSIONS: Whereas false positives were well controlled, particularly for RZ, power to detect DIF was suboptimal. Research is needed to examine the robustness of these methods under varying prior assumptions concerning the distribution of item and person parameters and when data fail to conform to prior assumptions. False identification of DIF when items were very easy to endorse is a problem warranting additional investigation.

Relationship of Religiosity and Spirituality to Hazardous Drinking, Drug Use, and Depression Among Sexual Minority Women.

Using data from Wave 3 of the Chicago Health and Life Experiences of Women (CHLEW) study (N = 699), we explored whether religiosity and spirituality were associated with risk of hazardous drinking, drug use, and depression among sexual minority women (SMW; i.e., lesbian, bisexual) and possible differences by race/ethnicity. Participants were more likely to endorse spirituality than religiosity, and endorsement of each was highest among African American SMW. We found no protective effect of religiosity or spirituality for hazardous drinking or drug use. An association initially found between identifying as very spiritual and past-year depression disappeared when controlling for help-seeking. Among SMW with high religiosity, African American SMW were more likely than White SMW to report hazardous drinking. Latina SMW with higher spirituality were more likely than White SMW to report drug use. Results suggest that religiosity and spirituality affect subgroups differently, which should be considered in future research on resiliency among SMW.

Relative precision, efficiency and construct validity of different starting and stopping rules for a computerized adaptive test: the GAIN substance problem scale.

Substance abuse treatment programs are being pressed to measure and make clinical decisions more efficiently about an increasing array of problems. This computerized adaptive testing (CAT) simulation examined the relative efficiency, precision and construct validity of different starting and stopping rules used to shorten the Global Appraisal of Individual Needs' (GAIN) Substance Problem Scale (SPS) and facilitate diagnosis based on it. Data came from 1,048 adolescents and adults referred to substance abuse treatment centers in 5 sites. CAT performance was evaluated using: (1) average standard errors, (2) average number of items, (3) bias in person measures, (4) root mean squared error of person measures, (5) Cohen's kappa to evaluate CAT classification compared to clinical classification, (6) correlation between CAT and full-scale measures, and (7) construct validity of CAT classification vs. clinical classification using correlations with five theoretically associated instruments. Results supported both CAT efficiency and validity.

Substance use disorder symptoms: evidence of differential item functioning by age.

This study examined the applicability of substance abuse diagnostic criteria for adolescents, young adults, and adults using the Global Appraisal of Individual Need's Substance Problems Scale (SPS) from 7,408 clients. Rasch analysis was used to: 1) evaluate whether the SPS operationalized a single reliable dimension, and 2) examine the extent to which the severity of each symptom and the overall test functioned the same or differently by age. Rasch analysis indicated that the SPS was unidimensional with a person reliability of .84. Eight symptoms were significantly different between adolescents and adults. Young adult calibrations tended to fall between adolescents and adults. Differential test functioning was clinically negligible for adolescents but resulted in about 7% more adults being classified as high need. These findings have theoretical implications for screening and treatment of adolescents vs. adults. SPS can be used across age groups though age-specific calibrations enable greater precision of measurement.

The unmet emotional, care/support, and informational needs of adult survivors of pediatric malignancies.

PURPOSE: This study describes the prevalence and predisposing factors for potentially modifiable unmet emotional, care/support, and information needs among adult survivors of childhood malignancies. METHODS: A randomly selected/stratified sample of participants in the Childhood Cancer Survivor Study (CCSS) responded to the CCSS-Needs Assessment Questionnaire (CCSS-NAQ) (n = 1189; mean [SD] current age, 39.7 [7.7], range = 26-61 years; 60.9 % women; mean [SD] years since diagnosis, 31.6 [4.7]). Survivors self-reported demographic information, health concerns, and needs; diagnosis/treatment data were obtained from medical records. Adjusted proportional risk ratios (prevalence ratios, PRs) were used to evaluate 77 separate needs. RESULTS: Fifty-four percent of survivors reported unmet psycho-emotional, 41 % coping, and 35 % care/support needs; 51, 35, and 33 %, respectively, reported unmet information needs related to cancer/treatment, the health care system, and surveillance. Female sex and annual income <$60K were associated with multiple needs; fewer needs were linked to diagnosis/years since/or age at diagnosis. Having moderate/extreme cancer-related anxiety/fear was associated with all needs, including a >6-fold increased prevalence for help dealing with "worry" (PR = 6.06; 95 % confidence interval [CI], 3.79-9.69) and anxiety (PR = 6.10; 95 % CI, 3.82-9.72) and a >5-fold increased prevalence for "needing to move on with life" (PR = 5.56; 95 % CI, 3.34-9.25) and dealing with "uncertainty about the future" (PR = 5.50; 95 % CI, 3.44-8.77). Radiation exposure and perceived health status were related to 42 and 29 needs, respectively. CONCLUSIONS: Demographic factors, disease/treatment characteristics, and intrapersonal factors can be used to profile survivors' unmet emotional, care/support, and information needs. IMPLICATIONS FOR CANCER SURVIVORS: These data can be used to enhance provider-survivor communication, identify at-risk subsamples, and appraise core intervention content.

Hormone replacement therapy and health behavior in postmenopausal polio survivors.

OBJECTIVES: Little is known about menopause and hormone replacement therapy (HRT) use in women with disabilities. The objectives of this study were to explore the health behaviors, health outcomes, and efficacy of HRT in a group of postmenopausal polio survivors and to compare selected outcomes to nationally representative cohorts. METHODS: One hundred and thirty-one postmenopausal polio survivors completed self-report surveys on health behaviors, HRT use, functional status, and psychosocial well-being. During a physical examination, fasting cholesterol and body mass index (BMI) were collected. Independent sample t-tests and Chi-square analysis were used to compare HRT users and non-users on health behaviors and health outcomes; logistic regression was used to predict HRT use. RESULTS: Prevalence of HRT use was 58%. Only BMI predicted HRT use (OR = 0.30, CI: 0.11-0.81). HRT users had better high density lipoprotein (HDL), low density lipoprotein, total cholesterol/HDL ratios, lower BMIs, were more confident when communicating with their physicians, more likely to discuss menopause with their physician, and experienced greater overall stress. HRT was not associated with health behavior, health-related quality of life, mood, or life satisfaction. Compared to non-disabled women, more of these women had higher total cholesterol, obesity, more sleeping problems, and were less likely to vigorously exercise or smoke. CONCLUSIONS: HRT did not confer substantial benefits in these postmenopausal polio survivors to warrant them using HRT at a higher rate than their non-disabled peers. Comparisons to their non-disabled peers suggested they may be at higher risk for adverse health problems associated with postmenopause.

Diabetes island: preliminary impact of a virtual world self-care educational intervention for african americans with type 2 diabetes.

BACKGROUND: Diabetes is a serious worldwide public health challenge. The burden of diabetes, including prevalence and risk of complications, is greater for minorities, particularly African Americans. Internet-based immersive virtual worlds offer a unique opportunity to reach large and diverse populations with diabetes for self-management education and support. OBJECTIVE: The objective of the study was to examine the acceptability, usage, and preliminary outcome of a virtual world intervention, Diabetes Island, in low-income African Americans with type 2 diabetes. The main hypotheses were that the intervention would: (1) be perceived as acceptable and useful; and (2) improve diabetes self-care (eg, behaviors and barriers) and self-care related outcomes, including glycemic control (A1C), body mass index (BMI), and psychosocial factors (ie, empowerment and distress) over six months. METHODS: The evaluation of the intervention impact used a single-group repeated measures design, including three assessment time points: (1) baseline, (2) 3 month (mid intervention), and (3) 6 month (immediate post intervention). Participants were recruited from a university primary care clinic. A total of 41 participants enrolled in the 6 month intervention study. The intervention components included: (1) a study website for communication, feedback, and tracking; and (2) access to an immersive virtual world (Diabetes Island) through Second Life, where a variety of diabetes self-care education activities and resources were available. Outcome measures included A1C, BMI, self-care behaviors, barriers to adherence, eating habits, empowerment, and distress. In addition, acceptability and usage were examined. A series of mixed-effects analyses, with time as a single repeated measures factor, were performed to examine preliminary outcomes. RESULTS: The intervention study sample (N=41) characteristics were: (1) mean age of 55 years, (2) 71% (29/41) female, (3) 100% (41/41) African American, and (4) 76% (31/41) reported annual incomes below US $20,000. Significant changes over time in the expected direction were observed for BMI (P<.02); diabetes-related distress (P<.02); global (P<.01) and dietary (P<.01) environmental barriers to self-care; one physical activity subscale (P<.04); and one dietary intake (P<.01) subscale. The participant feedback regarding the intervention (eg, ease of use, interest, and perceived impact) was consistently positive. The usage patterns showed that the majority of participants logged in regularly during the first two months, and around half logged in each week on average across the six month period. CONCLUSIONS: This study demonstrated promising initial results of an immersive virtual world approach to reaching underserved individuals with diabetes to deliver diabetes self-management education. This intervention model and method show promise and could be tailored for other populations. A large scale controlled trial is needed to further examine efficacy.

Medical assistant coaching to support diabetes self-care among low-income racial/ethnic minority populations: randomized controlled trial.

Innovative, culturally tailored strategies are needed to extend diabetes education and support efforts in lower-resourced primary care practices serving racial/ethnic minority groups. A randomized controlled trial (RCT) examined the effect of a diabetes self-care coaching intervention delivered by medical assistants and the joint effect of intervention and ethnicity over time. The randomized repeated-measures design included 270 low-income African American and Hispanic/Latino patients with type 2 diabetes. The 1-year clinic- and telephone-based medical assistant coaching intervention was culturally tailored and guided by theoretical frameworks. A1C was obtained, and a self-care measure was completed at baseline, 6 months, and 12 months. Data were analyzed using mixed-effects models with and without adjustment for covariates. There was a significant overall improvement in mean self-care scores across time, but no intervention effect. Results revealed differences in self-care patterns across racial/ethnic subgroups. No differences were found for A1C levels across time or group.

Correlates of self-care in low-income African American and Latino patients with diabetes.

OBJECTIVE: This study aimed to examine diabetes self-care (DSC) patterns in low-income African American and Latino patients with Type 2 diabetes, and identify patient-related, biomedical/disease-related, and psychosocial correlates of DSC. METHOD: We performed cross-sectional analysis of survey data from African Americans and Latinos aged ≥18 years with Type 2 diabetes (n = 250) participating in a diabetes self-management intervention at 4 primary care clinics. The Summary of Diabetes Self-Care Activities captured the subcomponents of healthy eating, physical activity, blood sugar testing, foot care, and smoking. Correlates included patient-related attributes, biomedical/disease-related factors, and psychosocial constructs, with their multivariable influence assessed with a 3-step model building procedure using regression techniques. RESULTS: Baseline characteristics were as follows: mean age of 53 years (SD = 12.4); 69% female; 53% African American; 74% with incomes below $20,000; and 60% with less than a high school education. DSC performance levels were highest for foot care (4.5/7 days) and lowest for physical activity (2.5/7 days). Across racial/ethnic subgroups, diabetes-related distress was the strongest correlate for DSC when measured as a composite score. Psychosocial factors accounted for 14% to 33% of variance in self-care areas for both racial/ethnic groups. Patient characteristics were more salient correlates in Hispanic/Latinos when examining the self-care subscales, particularly those requiring monetary resources. CONCLUSIONS: Important information is provided on specific DSC patterns in a sample of ethnic/racial minorities with Type 2 diabetes. Significant correlates found may help with identification and intervention of patients who may benefit from strategies to increase self-care adherence.

Development of a comprehensive health-related needs assessment for adult survivors of childhood cancer.

PURPOSE: Examine the construct validity, stability, internal consistency, and item-response performance of a self-report health needs assessment for adult survivors of childhood cancer. METHODS: A 190-item mailed survey was completed by 1,178 randomly selected (stratified on age, diagnosis, time since diagnosis) Childhood Cancer Survivor Study participants (mean age, 39.66 [SD 7.71] years; time since diagnosis, 31.60 [SD 4.71] years). Minorities and rural residents were oversampled at a 2:1 ratio. RESULTS: The final instrument included 135 items comprising nine unidimensional subscales (Psycho-emotional, Health System Concerns, Cancer-Related Health Information, General Health, Survivor Care and Support, Surveillance, Coping, Fiscal Concerns, and Relationships). Confirmatory factor analysis (n = 1,178; RMSEA = 0.020; 90 % CI = 0.019-0.020; CFI = 0.956; TLI = 0.955) and person-item fit variable maps established construct validity. Across subscales, Cronbach's alpha was 0.94-0.97, and the 4-week test-retest correlations were 0.52-0.91. In a Rasch analysis, item reliability was 0.97-0.99, person reliability was 0.80-0.90, and separation index scores were 2.00-3.01. Significant subscale covariates of higher need levels included demographics, diagnosis, and treatment exposures. CONCLUSIONS: The Childhood Cancer Survivor Study Needs Assessment Questionnaire (CCSS-NAQ) is reliable and construct-valid, has strong item-response properties, and discriminates need levels. IMPLICATIONS FOR CANCER SURVIVORS: The CCSS-NAQ potentially can be used to: (1) directly assess adult childhood cancer survivors' self-reported health-related needs, (2) identify individuals or subgroups with higher-level needs, (3) inform prevention and direct intervention strategies, and (4) facilitate prioritization of health-care resource allocation.

Dimensionality, hierarchical structure, age generalizability, and criterion validity of the GAIN's Behavioral Complexity Scale.

This study used Rasch measurement model criteria and traditional psychometric strategies to examine key psychometric properties of the Behavioral Complexity Scale (BCS), a widely used measure of externalizing disorders that focuses on attention deficit, hyperactivity, and conduct disorders. With a sample of 7,435 persons being screened for substance use disorders, the BCS was found to (a) be unidimensional, (b) have a hierarchical severity structure, (c) be generalizable to both youths and adults, and (d) meet hypothesized correlations with criterion variables. The BCS performed well as a unidimensional measure. The Rasch severity hierarchy of attention deficit to hyperactivity to conduct disorders provided a perspective that suggested that a dimensional measure could be used as an alternative and, in some ways, as an improvement to categorical diagnosis and common dimensional approaches. The finding of 3 low-severity conduct disorder items also supported a revision of categorical criteria, especially in substance use disorders.

A Comparison of Content-Balancing Procedures for Estimating Multiple Clinical Domains in Computerized Adaptive Testing: Relative Precision, Validity, and Detection of Persons With Misfitting Responses.

This simulation study sought to compare four different computerized adaptive testing (CAT) content balancing procedures designed for use in a multidimensional assessment with respect to measurement precision, symptom severity classification; validity of clinical diagnostic recommendations; and sensitivity to atypical responding. The four content balancing procedures were: (1) no content balancing, (2) Screener-based, (3) Mixed (Screener plus content balancing), and (4) Full content balancing. In Full content balancing and in Mixed content balancing following administration of the screener items, item selection was based on: (1) whether the target number of items for the item's subscale was reached, and (2) the item's information function. Mixed and Full content balancing provided the best representation of items from each of the main IMDS subscales. These procedures also resulted in higher CAT-to-full-scale correlations for the Trauma and Homicidal/Suicidal Thought subscales, and improved detection of atypical responding.

Validation of the Crime and Violence Scale (CVS) against the Rasch measurement model including differences by gender, race, and age.

In assessing criminality, researchers have used counts of crimes, arrests, and so on, because interval measures were not available. Additionally, crime seriousness varies depending on demographic factors. This study examined the Crime and Violence Scale (CVS) regarding psychometric quality using item response theory (IRT) and invariance of the crime seriousness hierarchy for gender, age, and racial/ethnic groups on 7,435 respondents. The CVS is a useful measure of criminality, though some items could be improved or dropped. Differential item functioning (DIF) analysis revealed that crime seriousness varies by age and gender. IRT shows promise in assessing and adjusting for demographic variations in crime seriousness.

A conceptual framework for improving the accessibility of fitness and recreation facilities for people with disabilities.

Access to fitness and recreation facilities is an important issue for people with disabilities. Although policy and legislation have helped to remove various environmental barriers, there remain a substantial number of inaccessible features in fitness and recreation facilities. This article presents an approach for improving the accessibility of fitness and recreation environments that enables participation and input from members of the community, as well as persons with expertise in accessibility. Through a collaboration between facilities, persons with disabilities and accessibility consultants, the approach provides a process of incremental change through readily achievable barrier removal and by providing an information and educational resource concerning barrier removal, disability awareness, and economic and information resources. Technology is incorporated to facilitate accessibility assessment, interaction between various stakeholders, and the creation of an accessibility solutions database. Policy implications of this approach are discussed.