Publications by authors named "Anita L Stewart"

99 Publications

The importance of patient engagement to quality of breast cancer care and health-related quality of life: a cross-sectional study among Latina breast cancer survivors in rural and urban communities.

BMC Womens Health 2021 Feb 9;21(1):59. Epub 2021 Feb 9.

National Institute on Minority Health and Health Disparities, National Institutes of Health, 9000 Rockville Pike, Building 3, Floor 5, Room E08, MD, 20892, Bethesda, USA.

Background: Compared to their white counterparts, Latina breast cancer survivors experience poorer quality of care and worse health-related quality of life. Limited English proficiency (LEP) and patient engagement in cancer care could help explain these disparities. We assessed associations between LEP status and difficulty engaging with physicians, with self-reported quality of breast cancer care and health-related quality of life (physical and emotional well-being) among rural and urban Latina breast cancer survivors.

Methods: Analyses used cross-sectional baseline survey data from two studies that tested a stress management program among rural and urban Latina breast cancer survivors in California. Medical information was collected through medical records review. Linear regression models examined bivariate and multivariable associations of LEP status (yes or no), difficulty engaging with doctors (asking questions and participating in treatment decisions) (1-4; higher score = greater difficulty), and rural versus urban site, with three outcomes: (1) quality of breast cancer care and information; (2) physical well-being; and (3) and emotional well-being, controlling for demographic and medical factors.

Results: The total sample included 304 women (151 from urban and 153 from rural sites). Mean age was 52.7 years (SD 10.9). Most were limited English proficient (84.5%) and had less than a high school education (67.8%). Difficulty engaging with doctors was inversely associated with patient ratings of quality of breast cancer care and information (B = - 0.190, p = 0.014), emotional well-being (B = - 1.866, p < 0.001), and physical well-being (B = - 1.272, p = 0.002), controlling for demographic and treatment factors. LEP (vs. not; B = 1.987, p = 0.040) was independently associated with physical well-being only. Rural/urban status was not related independently to any outcome.

Conclusions: Rural and urban Latina breast cancer survivors who report greater difficulty engaging with physicians experienced worse quality of breast cancer care and health-related quality of life. Promoting greater engagement of Latina breast cancer survivors in cancer care and providing medical interpreters when needed could improve patient outcomes among this vulnerable group.

Trial Registration: http://www.ClinicalTrials.gov identifier NCT02931552 and NCT01383174.
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http://dx.doi.org/10.1186/s12905-021-01200-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871405PMC
February 2021

Patient-physician interpersonal processes of care at the time of diabetes treatment intensification and their links to patient outcomes.

Patient Educ Couns 2020 Dec 25. Epub 2020 Dec 25.

Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Objective: To investigate how patient-physician interpersonal processes of care are related to levels of diabetes-related distress, diabetes medication-taking behavior, and HbA1c during conversations with patients about intensifying medication.

Methods: We randomly recruited 1270 patients from diabetes specialty clinics in Tehran, Iran who were taking an additional oral diabetes medication or starting insulin during the prior 3 months. This interviewer-administered cross-sectional survey assessed multiple aspects of patient-physician interpersonal processes, diabetes-related distress, and diabetes medication-taking. Clinical history and HbA1c were collected from electronic medical records. Regression estimates and Structural Equation Modeling were used to test associations.

Results: Some communication scales indicated a significant relationship with total diabetes distress (P < 0.001). Diabetes medication-taking was associated with less diabetes distress (adjusted odds ratio [aOR]=0.45, P < 0.001), lower Hurried Communication (aOR=0.72, P = 0.013), higher Elicited Concerns (aOR=1.30, P = 0.012), and higher Explained Results (aOR=1.41, P < 0.001) scores. SEM analyses showed medication-taking behavior was associated with a 0.68 decrease in HbA1c. Hurried Communication and diabetes distress were directly associated with HbA1c.

Conclusion: Aspects of patient-physician interpersonal processes at the time of intensifying diabetes treatment may be related to experiencing less distress, effective medication-taking, and improved HbA1c.

Practice Implications: The results are intended to inform communication strategies that physicians might incorporate into practice.
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http://dx.doi.org/10.1016/j.pec.2020.12.008DOI Listing
December 2020

Guidelines for Evaluating the Feasibility of Recruitment in Pilot Studies of Diverse Populations: An Overlooked but Important Component.

Ethn Dis 2020 19;30(Suppl 2):745-754. Epub 2020 Nov 19.

Columbia University Stroud Center at New York State Psychiatric Institute and Columbia Center for Interdisciplinary Research on Alzheimer's Disease Disparities (CIRAD), New York, NY.

Background: In health disparities research, studies often fall short of their recruitment goals. Conducting a pilot feasibility study of recruitment in which data are collected systematically on recruitment processes can help investigators refine methods for the larger study. However, there are few guidelines for conducting pilot feasibility studies, and recruitment methods are seldom the focus. Feasibility indicators differ from traditional reports of recruitment results by focusing on the extent to which recruitment goals are met.

Methods: We present an organizing framework for assessing the feasibility of recruitment that includes eight steps, briefly: 1) specify recruitment goals; 2) specify recruitment processes; 3) establish a tracking system for each individual; 4) establish a tracking database for monitoring processes and results; 5) implement recruitment and track each individual's progress; 6) summarize recruitment results; 7) calculate and interpret feasibility measures - were goals met; and 8) if goals were not met, utilize tracking data to modify methods for the larger study. We describe methods within each step, with added details for steps 2-5 (the specific processes). The framework draws from a small literature on recruitment feasibility with a focus on health disparities populations. The guidelines blend well-known methods of recruitment with additional information on calculating feasibility indicators.

Conclusions: These guidelines provide a first step in thinking systematically about recruitment feasibility, to advance the field of measuring feasibility. Feasibility indicators also can be used to track the effectiveness of innovative recruitment strategies as part of building the science of recruitment, especially in disparities populations.
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http://dx.doi.org/10.18865/ed.30.S2.745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7683033PMC
November 2020

Development and Evaluation of the 8-item Caregiver Self-Efficacy Scale (CSES-8).

Gerontologist 2020 Nov 4. Epub 2020 Nov 4.

Department of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA.

Background And Objectives: This paper describes the development and evaluation of a short caregiving self-efficacy measure. The self-administered 8-item Caregiver Self-efficacy Scale (CSES-8) was developed to reflect components of typical caregiver-support interventions and to be practical for inclusion in future self-efficacy and caregiving research.

Research Design And Methods: We administered the CSES-8 in two samples: participants in an intervention for caregivers of persons with cognitive disabilities, and a voluntary on-line survey for caregivers of adults. We evaluated the completion rate, item-scale correlations, reliability, descriptive statistics, and preliminary construct validity of the CSES-8 in both samples, and sensitivity to change in the intervention sample.

Results: The intervention caregivers' sample (N=158) was 85% female (mean age=65 years). The on-line survey sample (N=138) was 90% female (mean age=78). In both samples, the CSES-8 had excellent internal-consistency reliability (0.89 and 0.88) and good distribution with sufficient variability to detect change. Test-retest reliability was good in the on-line sample (0.73). As evidence of construct validity, most hypotheses were confirmed in both samples. The CSES-8 was sensitive to change at 6 months for caregivers in the intervention program (p < .001).

Discussion And Implications: The CSES-8 is short, comprehensive with respect to common components of interventions to improve caregivers' quality of life, and sensitive to change. It can serve a useful role exploring mechanisms by which caregiver intervention studies work, and it can be helpful in examining whether self-efficacy mediates the effect of these intervention on various outcomes such as psychological well-being.
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http://dx.doi.org/10.1093/geront/gnaa174DOI Listing
November 2020

Multi-cultural perspectives on group singing among diverse older adults.

Geriatr Nurs 2020 Nov - Dec;41(6):1006-1012. Epub 2020 Aug 8.

Institute for Health & Aging, School of Nursing, University of California San Francisco, 3333 California Street, Suite 340, San Francisco, CA 94118, United States.

Group choir singing has been shown to have health benefits for older adults. However, because most studies have included predominantly white participants, it is unknown whether findings generalize to older adults from more diverse backgrounds. This multi-site qualitative study assessed perceived benefits of group singing for socioeconomically and racially/ethnically diverse older adults. We interviewed 31 choir participants, 6 music professionals and 6 administrators involved in a large, cluster-randomized trial. We used content analysis to identify themes. Psychosocial engagement was most commonly reported, with six components: emotional well-being, self-esteem, self-confidence, social connection and support, decreased loneliness, and cultural identity and multi-cultural appreciation. A few reported cognitive and physical benefits. They also suggest that group singing among ethnically diverse older adults can have multiple psychosocial benefits and enhance a sense of cultural identity and appreciation of other cultures. These findings can help in selecting structured outcome measures for choir interventions.
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http://dx.doi.org/10.1016/j.gerinurse.2020.07.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738424PMC
August 2020

Exploring the effects of visual and literary arts interventions on psychosocial well-being of diverse older adults: a mixed methods pilot study.

Arts Health 2020 Aug 3:1-15. Epub 2020 Aug 3.

New Art Horizons , Pacifica, CA, USA.

Background: Engagement in the arts may have health benefits for older adults. Most research has focused on music and dance; less is known about the benefits of other arts interventions. The purpose of this study was to examine the effects of visual (ceramics and collage) and literary arts (storytelling and writing) on well-being.

Methods: We used mixed methods to examine the effects of a 12-week visual or literary arts intervention on well-being. Adults age 55 and over from four housing sites were assigned to start an intervention immediately (intervention) or wait 12 weeks (controls). The study included pre/post-test measures of well-being and focus groups about perceived benefits.

Results: Compared to controls, participants in the ceramics intervention had significant improvements in interest in life and mastery, while no changes were observed after the storytelling intervention. Seven psychosocial benefits were identified .

Conclusions: Participation in visual and literary arts for older adults was associated with well-being media.
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http://dx.doi.org/10.1080/17533015.2020.1802603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7856091PMC
August 2020

Nuevo Amanecer-II: Results of a randomized controlled trial of a community-based participatory, peer-delivered stress management intervention for rural Latina breast cancer survivors.

Psychooncology 2020 11 7;29(11):1802-1814. Epub 2020 Aug 7.

Kaweah Delta Health Care District, Visalia, California, USA.

Objective: We report results of a community-based multisite, randomized controlled trial of Nuevo Amanecer (NA-II), a 10-week stress management program for rural, low literacy Latina breast cancer survivors.

Methods: Trained peers delivered NA-II to Spanish-speaking Latinas with non-metastatic breast cancer in three rural communities. Women were randomized to receive the program immediately or wait 6 months. Assessments were conducted at baseline, 3 months, and 6 months. Primary outcomes were breast cancer-specific quality of life domains; secondary outcomes included general distress symptoms and stress management skills. Intention-to-treat analyses using repeated-measures linear regression models estimated changes in slope between groups.

Results: Of 153 participants (76 randomized to intervention, 77 to control group), 92% were retained at 6 months. Mean age was 54.8 years (SD = 10.5); 80% had less than high school education. There were no statistically significant treatment × time effects on quality of life. Compared to women in the control group, intervention group women reported greater improvements in anxiety at 6 months (-0.20 vs -0.02, P = .049; range 0-4) as well as three stress management skills: relaxation at 3 months (+0.98 vs -0.07, P < .0001; range 0-4) and 6 months (+0.82 vs +0.04, P < .001), awareness of tension at 3 months (+0.31 vs -0.19, P < .01; range 0-4) and 6 months (+0.29 vs -0.11, P < .05), and coping confidence at 3 months (+0.12 vs -0.23, P < .01; range 0-4).

Conclusions: Stress management programs delivered by trained peers in rural community settings can reduce anxiety and improve stress management skills among Latina breast cancer survivors.
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http://dx.doi.org/10.1002/pon.5481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754127PMC
November 2020

Patient-physician communication in the context of diabetes care: Adaptation and assessment of psychometric properties of a Persian version of the interpersonal process of care survey (P-IPC).

Diabetes Res Clin Pract 2020 Apr 17;162:108109. Epub 2020 Mar 17.

Department of Health Education & Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. Electronic address:

Aims: To examine the psychometric characteristics and explore the preliminary validity of the Persian version of the Interpersonal Processes of Care Survey (P-IPC) to assess patient-physician communication in the context of diabetes care.

Methods: After adapting, translating, examining content validity, and pretesting the questionnaire, it was administered to 300 patients with diabetes. Confirmatory factor analysis identified the factor structure (scales). Variability, item-scale correlations, reliability, and construct validity of the final scales were examined.

Results: Factor analysis supported the hypothesized second-order factor model with 27 of the 29 items:11 first-, and 7 second-order common factors. Scale scores were calculated for the 7 second-order factors. Internal-consistency reliability for the 7 scales ranged from 0.60 to 0.90 and 2-week test-retest correlations ranged from 0.89 to 0.96. The communication and interpersonal style domains of the P-IPC demonstrated high ceiling effects suggesting good patient-physician communication. The P-IPC scales differentiated between patients in the language-concordant and language-discordant groups, and patterns of correlations with three patient satisfaction measures corresponded to hypotheses.

Conclusion: The P-IPC includes all of the second-order scales identified in the original IPC. Evidence of its reliability and validity suggest it can be useful for assessing patient-physician communication in the context of diabetes care.
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http://dx.doi.org/10.1016/j.diabres.2020.108109DOI Listing
April 2020

Participant-Centered Strategies for Overcoming Barriers to Biospecimen Collection among Spanish-Speaking Latina Breast Cancer Survivors.

Cancer Epidemiol Biomarkers Prev 2020 03;29(3):606-615

National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland.

Background: Latinos are underrepresented in biomedical research, particularly biomarker research, yet they constitute the nation's largest ethnic/racial minority. Optimal methods for obtaining biospecimens for biomarker research among Latinos need to be identified. To minimize barriers and enhance participation, this study developed and tested tailored strategies for collecting biomarkers of chronic stress and premature aging among Spanish-speaking Latina breast cancer survivors.

Methods: This study used a community-based participatory approach and selected hair and saliva as noninvasive biospecimens to assess telomere length, the cortisol awakening response (CAR), and hair cortisol concentration. We developed bilingual multimedia instructional materials, and community health workers assisted in collections. Telephone surveys assessed willingness to participate in future studies, barriers to sample collection, and recommendations for improving the strategies.

Results: A total of 103 participants were recruited over 18 months from two rural sites in California, and 88 were retained at 6-month follow-up. At baseline, rates of donating salivary DNA for telomere length measurement, saliva for CAR analysis, and hair for cortisol concentration were 98%, 89%, and 52%, respectively. At follow-up, rates were 83%, 76%, and 55%, respectively. The majority of participants reported being very willing to provide hair (72%) or saliva (74%) for future studies.

Conclusions: Our results support the feasibility of including minorities in biomedical research. We report excellent rates of saliva collection when community partners are engaged in the process, and when patient-centered and culturally tailored recruitment methods are implemented.

Impact: The development of methods to facilitate the inclusion of minorities in biomedical research is critical to eliminate racial/ethnic health disparities.
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http://dx.doi.org/10.1158/1055-9965.EPI-19-0942DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062229PMC
March 2020

Understanding the Psychological Distress of Food Insecurity: A Qualitative Study of Children's Experiences and Related Coping Strategies.

J Acad Nutr Diet 2020 03 17;120(3):395-403. Epub 2020 Jan 17.

Background: Food insecurity, a condition of inadequate household food availability, affects 15.7% of US households with children. Food insecurity is generally believed to affect the quantity and quality of food consumed. However, an understudied but important aspect of the experience of food insecurity is psychological distress.

Objective: To critically explore the psychological distress associated with children's food insecurity using children's own reports of their experiences.

Design: In-depth qualitative interviews conducted with children to better understand the psychological distress associated with food insecurity.

Participants/setting: Sixty children (aged 7 to 14 years) were recruited from the San Francisco Bay Area. Children were eligible in the case that they spoke English fluently and their parent reported any experience of household food insecurity during the past year.

Results: Children discussed six themes related to the psychological distress associated with food insecurity: worrying about not having enough food, worrying about their parents' well-being, anger and frustration about not having enough food, embarrassment about their family's food situation, strain on the family's dynamics due to food insecurity, and sadness over not having enough food. After describing their experiences, children described strategies they employed to tolerate or cope with food insecurity, including distracting from or using their imagination to cope with food insecurity, increasing tolerance of their family's food situation, and appreciating their parents for providing food and resources.

Conclusions: Food insecurity contributes to children's psychological distress. Given the known effects of chronic stress in childhood, the psychological distress of food insecurity may represent an important mechanism by which food insecurity adversely influences children's growth and development and deserves investigation in future studies.
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http://dx.doi.org/10.1016/j.jand.2019.10.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7047973PMC
March 2020

Translating a stress management intervention for rural Latina breast cancer survivors: The Nuevo Amanecer-II.

PLoS One 2019 16;14(10):e0224068. Epub 2019 Oct 16.

National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland, United States of America.

Objectives: Adapt a cognitive-behavioral stress management program (Nuevo Amanecer or NA) to be generalizable to rural, low literacy Spanish-speaking Latinas with breast cancer survivors at all phases of survivorship.

Methods: Apply the Transcreation Framework, a community-engaged translational model, to develop the adapted program (Nuevo Amanecer or NA-II), design a randomized controlled trial for community settings, identify recruiters and interventionists, and recruit participants into the trial.

Results: Adaptations included expanding the program from eight to ten weeks, simplifying materials, and increasing skills practice. We added stress management videos, healthy lifestyles information, and survivorship information. Interventionists were trained Latina breast cancer survivors. All core components of NA were retained in NA-II including managing the impact of cancer, information on breast cancer and its treatment, finding cancer information, getting support, managing thoughts, stress management techniques, and setting goals. Participants receive a program manual. Each session includes a review of that week's content using the manual, practicing a stress-management skill, setting a specific goal, and reviewing videos. Spanish-speaking Latinas with non-metastatic breast cancer were recruited by community recruiters. Of 231 women approached, 24% refused, 10% were ineligible, and 153 (66%) were randomized to the intervention or a wait-list control group. The sample was vulnerable: 69% had < high school education, more than half had only Medicaid or no insurance, 91% was foreign born, and 48% reported financial hardship in the past year.

Conclusions: Applying the Transcreation Framework to engage stakeholders in designing community-based RCTs enhanced congruence with community contexts and recruitment of this vulnerable population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0224068PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6795501PMC
March 2020

Feasibility of a Mobile Phone App and Telephone Coaching Survivorship Care Planning Program Among Spanish-Speaking Breast Cancer Survivors.

JMIR Cancer 2019 Jul 9;5(2):e13543. Epub 2019 Jul 9.

Círculo de Vida Cancer Support and Resource Center, San Francisco, CA, United States.

Background: Spanish-speaking Latina breast cancer survivors experience disparities in knowledge of breast cancer survivorship care, psychosocial health, lifestyle risk factors, and symptoms compared with their white counterparts. Survivorship care planning programs (SCPPs) could help these women receive optimal follow-up care and manage their condition.

Objective: This study aimed to evaluate the feasibility, acceptability, and preliminary efficacy of a culturally and linguistically suitable SCPP called the Nuevo Amanecer (New Dawn) Survivorship Care Planning Program for Spanish-speaking breast cancer patients in public hospital settings, approaching the end of active treatment.

Methods: The 2-month intervention was delivered via a written bilingual survivorship care plan and booklet, Spanish-language mobile phone app with integrated activity tracker, and telephone coaching. This single-arm feasibility study used mixed methods to evaluate the intervention. Acceptability and feasibility were examined via tracking of implementation processes, debriefing interviews, and postintervention satisfaction surveys. Preliminary efficacy was assessed via baseline and 2-month interviews using structured surveys and pre- and postintervention average daily steps count based on activity tracker data. Primary outcomes were self-reported fatigue, health distress, knowledge of cancer survivorship care, and self-efficacy for managing cancer follow-up health care and self-care. Secondary outcomes were emotional well-being, depressive and somatic symptoms, and average daily steps.

Results: All women (n=23) were foreign-born with limited English proficiency; 13 (57%) had an elementary school education or less, 16 (70%) were of Mexican origin, and all had public health insurance. Coaching calls lasted on average 15 min each (SD 3.4). A total of 19 of 23 participants (83%) completed all 5 coaching calls. The majority (n=17; 81%) rated the overall quality of the app as "very good" or "excellent" (all rated it as at least "good"). Women checked their daily steps graph on the app between 4.2 to 5.9 times per week. Compared with baseline, postintervention fatigue (B=-.26; P=.02; Cohen d=0.4) and health distress levels (B=-.36; P=.01; Cohen d=0.3) were significantly lower and knowledge of recommended follow-up care and resources (B=.41; P=.03; Cohen d=0.5) and emotional well-being improved significantly (B=1.42; P=.02; Cohen d=0.3); self-efficacy for managing cancer follow-up care did not change. Average daily steps increased significantly from 6157 to 7469 (B=1311.8; P=.02; Cohen d=0.5).

Conclusions: We found preliminary evidence of program feasibility, acceptability, and efficacy, with significant 2-month improvements in fatigue, health distress, and emotional well-being and increased knowledge of recommended follow-up care and average daily steps. Tailored mobile phone and health coaching SCPPs could help to ensure equitable access to these services and improve symptoms and physical activity levels among Spanish-speaking Latina breast cancer survivors.
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http://dx.doi.org/10.2196/13543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647762PMC
July 2019

Mentes Positivas en Acción: Feasibility Study of a Promotor-Delivered Cognitive Behavioral Stress Management Program for Low-Income Spanish-Speaking Latinas.

Health Equity 2019 26;3(1):155-161. Epub 2019 Apr 26.

Center for Aging in Diverse Communities, University of California San Francisco (UCSF), San Francisco, California.

Low-income Latino immigrants lack access to mental health providers. We explored the feasibility of training promotores to deliver a stress management program in community settings. We trained promotores to deliver an 8-week intervention program comprising evidence-based cognitive-behavioral stress management techniques. Trained promotores then delivered the program to Spanish-speaking Latino immigrants. Promotores (=10) improved their knowledge significantly after the training (<0.001) and delivered the program demonstrating excellent fidelity. Participants who received the program (=50) had significantly improved scores on immigration stress, perceived stress, and depressive symptoms (<0.001). It is feasible to train Latino promotores to deliver an effective stress management program to low-income Latino immigrants in their communities. Results contribute to a growing literature on the value of such interventions in community settings. If it is found to be effective in future studies, the program could help fill a large need in the Latino community.
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http://dx.doi.org/10.1089/heq.2019.0012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6608695PMC
April 2019

Social support as a moderator in the relationship between intrusive thoughts and anxiety among Spanish-speaking Latinas with breast cancer.

Psychooncology 2019 09 18;28(9):1819-1828. Epub 2019 Jul 18.

National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, Maryland.

Objective: Intrusive thoughts, defined as unwanted and recurrent thoughts about a stressful experience, are associated with psychological distress in women with breast cancer. This study assessed moderating effects of various social support dimensions on associations between intrusive thoughts and psychological distress among Latina breast cancer survivors.

Methods: We used baseline data from a randomized controlled trial of a stress management intervention delivered to 151 Spanish-speaking Latinas with nonmetastatic breast cancer within 1 year of diagnosis. Intrusive thoughts, four dimensions of social support (emotional/informational, tangible, affectionate, and positive social interaction), and symptoms of anxiety and depression were assessed through in-person interviews. Information on age, time since diagnosis, breast cancer variables, history of depression, and marital status served as covariates. Generalized linear models were used to investigate bivariate and multivariate associations and to explore moderation effects of the four dimensions of social support.

Results: In bivariate models, intrusive thoughts were associated positively with depression (β = .024, .001) and anxiety (β = .047, P < .001) symptoms. Adjusting for other factors, intrusive thoughts remained associated with depression symptoms (β = .022, .008), regardless of level of social support (for all support dimensions). For anxiety, there were significant interactions of tangible (β = -.013, .034) and affectionate (β = -.022, .005) support with intrusive thoughts. Intrusive thoughts were associated more strongly with anxiety symptoms among women reporting less tangible and affectionate support than those with higher levels of these types of support.

Conclusions: Tangible and affectionate support have protective effects on anxiety symptoms among Spanish-speaking Latina breast cancer survivors experiencing intrusive thoughts, but not depression symptoms.
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http://dx.doi.org/10.1002/pon.5154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6771841PMC
September 2019

A Community Choir Intervention to Promote Well-Being Among Diverse Older Adults: Results From the Community of Voices Trial.

J Gerontol B Psychol Sci Soc Sci 2020 02;75(3):549-559

Center for Aging in Diverse Communities, University of California San Francisco, Bethesda, Maryland.

Objectives: To test effects of the Community of Voices choir intervention on the health, well-being, and health care costs of racial/ethnically diverse older adults.

Method: Twelve Administration-on-Aging-supported senior centers were cluster randomized into two groups: the intervention group started the choir immediately and a wait-list control group began the choir 6 months later. The choir program was designed for community-dwelling adults aged 60 years and older. The multimodal intervention comprises activities that engage participants cognitively, physically, and socially. Outcome measures assessed these three domains as well as health care utilization and costs. The intention-to-treat comparison was at 6 months.

Results: The sample (N = 390) had a mean age of 71.3 years (SD = 7.2); 65% were nonwhite. Six-month retention was 92%. Compared to controls, intervention group members experienced significantly greater improvements in loneliness (p = .02; standardized effect size [ES = 0.34] and interest in life (p = .008, ES = 0.39). No significant group differences were observed for cognitive or physical outcomes or for health care costs.

Discussion: Findings support adoption of community choirs for reducing loneliness and increasing interest in life among diverse older adults. Further efforts need to examine the mechanisms by which engagement in choirs improves aspects of well-being and reduces health disparities among older adults, including potential longer-term effects.

Clinicaltrials.gov Registration: NCT01869179 registered January 9, 2013.
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http://dx.doi.org/10.1093/geronb/gby132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328053PMC
February 2020

Development and Preliminary Validation of the Lung Transplant Quality of Life (LT-QOL) Survey.

Am J Respir Crit Care Med 2019 04;199(8):1008-1019

4 Institute for Health & Aging, University of California, San Francisco, San Francisco, California.

Rationale: Although lung transplantation aims to improve health-related quality of life (HRQL), existing instruments fail to include health domains considered important in this population.

Objectives: We aimed to develop a comprehensive lung transplant-specific instrument to address this shortcoming.

Methods: We developed a pool of 126 candidate items addressing domains previously identified as important by lung transplant recipients. Through cognitive interviews conducted in 43 transplant recipients, items deemed irrelevant or redundant were dropped. The 84 remaining items were field tested in lung transplant recipients. Exploratory and confirmatory factor analyses were used to evaluate the factor structure, and scales were evaluated for internal consistency and construct validity.

Measurements And Main Results: The 84-item preliminary survey was administered to 201 lung transplant recipients with a mean age of 57.9 (±12.7) years; 46% were female. After factor analyses and internal consistency evaluation, we retained 60 items comprising the Lung Transplant Quality of Life (LT-QOL) Survey. The LT-QOL contains 10 scales that measure symptoms, health perceptions, functioning, and well-being. The confirmatory factor analysis model had good approximate fit (comparative fit index = 0.990; standardized root-mean-square residual = 0.062). Cronbach αs for the 10 scales ranged from 0.75 to 0.95. Interscale correlations were consistent with hypothesized relationships. Subjects with severe chronic lung allograft dysfunction (n = 13) reported significantly worse HRQL than subjects without chronic lung allograft dysfunction (n = 168) on 6 of the 10 LT-QOL scales.

Conclusions: The LT-QOL is a new, multidimensional instrument that characterizes and quantifies HRQL in lung transplant recipients.
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http://dx.doi.org/10.1164/rccm.201806-1198OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467318PMC
April 2019

Transcreation: an implementation science framework for community-engaged behavioral interventions to reduce health disparities.

BMC Health Serv Res 2018 Sep 12;18(1):710. Epub 2018 Sep 12.

University of California San Francisco, 3333 California Street, Suite 350E, San Francisco, CA, 94118, USA.

Background: Methods for translating evidence-based behavioral interventions into real-world settings seldom account for the special issues in reaching health disparity populations.

Main Text: The objective of this article is to describe an innovative "transcreational" framework for designing and delivering interventions in communities to reduce health disparities. We define transcreation as the process of planning, delivering, and evaluating interventions so that they resonate with the community experiencing health disparities, while achieving intended health outcomes. The Transcreation Framework for Community-engaged Behavioral Interventions to Reduce Health Disparities comprises seven steps: 1) identify community infrastructure and engage partners; 2) specify theory; 3) identify multiple inputs for new program; 4) design intervention prototype; 5) design study, methods, and measures for community setting; 6) build community capacity for delivery; and 7) deliver transcreated intervention and evaluate implementation processes. Communities are engaged from the start and interventions are delivered by community-based interventionists and tested in community settings. The framework applies rigorous scientific methods for evaluating program effectiveness and implementation processes. It incorporates training and ongoing technical assistance to assure treatment fidelity and build community capacity.

Conclusions: This framework expands the types of scientific evidence used and balances fidelity to evidence and fit to the community setting. It can guide researchers and communities in developing and testing behavioral interventions to reduce health disparities that are likely to be sustained because infrastructure development is embedded in the research.
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http://dx.doi.org/10.1186/s12913-018-3521-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134771PMC
September 2018

Understanding racial/ethnic differences in breast cancer-related physical well-being: the role of patient-provider interactions.

Breast Cancer Res Treat 2018 Aug 5;170(3):593-603. Epub 2018 Apr 5.

Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.

Purpose: Racial/ethnic differences in cancer symptom burden are well documented, but limited research has evaluated modifiable factors underlying these differences. Our objective was to examine the role of patient-provider interactions to help explain the relationship between race/ethnicity and cancer-specific physical well-being (PWB) among women with breast cancer.

Methods: The Pathways Study is a prospective cohort study of 4505 women diagnosed with breast cancer at Kaiser Permanente Northern California between 2006 and 2013. Our analysis included white, black, Hispanic, and Asian participants who completed baseline assessments of PWB, measured using the Functional Assessment of Cancer Therapy for Breast Cancer, and patient-provider interactions, measured by the Interpersonal Processes of Care Survey (IPC) (N = 4002). Using step-wise linear regression, we examined associations of race/ethnicity with PWB, and changes in associations when IPC domains were added.

Results: We observed racial/ethnic differences in PWB, with minorities reporting lower scores than whites (beta, black: - 1.79; beta, Hispanic: - 1.92; beta, Asian: - 1.68; p < 0.0001 for all comparisons). With the addition of health and demographic covariates to the model, associations between race/ethnicity and PWB score became attenuated for blacks and Asians (beta: - 0.63, p = 0.06; beta: - 0.68, p = 0.02, respectively) and, to a lesser extent, for Hispanic women (beta: - 1.06, p = 0.0003). Adjusting for IPC domains did not affect Hispanic-white differences (beta: - 1.08, p = 0.0002), and slightly attenuated black-white differences (beta: - 0.51, p = 0.14). Asian-white differences narrowed substantially (beta: - 0.31, p = 0.28).

Conclusions: IPC domains, including those capturing perceived discrimination, respect, and clarity of communication, appeared to partly explain PWB differences for black and Asian women. Results highlight opportunities to improve providers' interactions with minority patients, and communication with minority patients about their supportive care needs.
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http://dx.doi.org/10.1007/s10549-018-4776-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6528788PMC
August 2018

Recruitment and baseline characteristics of the Community of Voices choir study to promote the health and well-being of diverse older adults.

Contemp Clin Trials Commun 2017 Dec 17;8:106-113. Epub 2017 Sep 17.

Institute for Health & Aging, University of California, San Francisco, CA, USA.

Objective: To describe the recruitment and baseline results of the Community of Voices study that aims to examine the effect of a community choir intervention on the health and well-being of older adults from diverse racial/ethnic and socioeconomic backgrounds.

Method: Using community-based participatory research methods, we recruited adults age 60 and over from 12 Administration on Aging-supported senior centers in San Francisco into a 2-arm cluster-randomized controlled trial of the community choir intervention. Multiple outreach methods were used. We tracked outreach, screening, and recruitment metrics and collected demographics and baseline outcomes via community-based, interviewer-administered surveys and performance measures of cognition, physical function, and psychosocial variables.

Results: The study contacted 819 individuals, screened 636, and enrolled 390 diverse older adults over a 42-month, phased recruitment period. The mean age was 71.2 (SD = 7.3), and the majority were women. Two-thirds of the sample are non-white, and 20% of participants reported having financial hardship.

Discussion: Outreach and recruitment methods used in the Community of Voices trial facilitated enrollment of a large proportion of minority and lower-SES older adults in the final sample. Similar recruitment approaches could serve as a model for recruiting diverse racial/ethnic and socioeconomic older adults into research.
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http://dx.doi.org/10.1016/j.conctc.2017.09.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5791898PMC
December 2017

Commentary: Copyright Restrictions Versus Open Access to Survey Instruments.

Med Care 2018 02;56(2):107-110

Center for Aging in Diverse Communities, Institute for Health & Aging, University of California, San Francisco, CA.

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http://dx.doi.org/10.1097/MLR.0000000000000857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5766425PMC
February 2018

Post-Treatment Survivorship Care Needs of Spanish-speaking Latinas with Breast Cancer.

J Community Support Oncol 2017 ;15(1):20-27

Biology Scholars Program, University of California, Berkeley, 2075 Valley Life Science Building, Berkeley, California 94720-3120 USA.

Background: A comprehensive assessment of Spanish-speaking breast cancer survivors' (SSBCS) survivorship needs is lacking.

Objective: Assess SSBCS' post-treatment symptom management, psychosocial, and informational needs.

Methods: 118 telephone surveys and 25 in-person semi-structured interviews with SSBCS, and semi-structured interviews with 5 support providers and 4 physicians who serve SSBCS from 5 Northern California counties.

Results: Surveys identified the most bothersome (bothered by it in the past month "somewhat/quite a bit/a lot") physical symptoms as: joint pain, fatigue, hot flashes, numbness in hands/feet, and vaginal dryness. The most bothersome emotional symptoms were thoughts of recurrence/new cancers, depression/sadness, anxieties, and stress. Seven themes emerged from interviews: 1) unmet physical symptom management needs; 2) social support from family/friends often ends when treatment is completed; 3) challenges resuming roles; 5) sense of abandonment by health care system when treatment ends; 6) need for formal transition from active treatment to follow-up care; 6) fear of recurrence especially when obtaining follow-up care; and 7) desire for information on late effects of initial treatments and side effects of hormonal treatments. Based on survey and interview results, we present a conceptual framework for survivorship care interventions for SSBCS.

Limitations: Sample may not represent SSBCS' concerns seen outside of Northern California hospitals.

Conclusions: Physical and psychosocial symptoms were common. SSBCS need culturally appropriate survivorship care programs that address symptom management, psychosocial concerns, follow-up care, and healthy lifestyles.
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http://dx.doi.org/10.12788/jcso.0325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608026PMC
January 2017

Evaluating the Implementation of a Translational Peer-Delivered Stress Management Program for Spanish-Speaking Latina Breast Cancer Survivors.

J Cancer Educ 2018 08;33(4):875-884

New York University Medical Center, New York, NY, USA.

Information is needed on implementation processes involved in translating evidence-based interventions (EBIs) into health disparity communities. In an RCT, Nuevo Amanecer, a cognitive-behavioral stress management (CBSM) program delivered by breast cancer survivors (compañeras) in community settings to Spanish-speaking Latina breast cancer survivors, was effective in improving quality of life and decreasing breast cancer concerns and depressive and bodily symptoms. Using mixed methods, we evaluated the processes of implementing Nuevo Amanecer. Program delivery was assessed by direct observation. Treatment receipt was assessed by participants' mastery and homework completion. Perceived benefits, quality, ease of use, usefulness of components, and suggested improvements were evaluated through participant surveys and semi-structured interviews of participants and compañeras. Eighty percent of women completed six or more of eight sessions. Observer ratings of program delivery indicated compañeras demonstrated fidelity 80-90% of the time for three components (e.g., following the manual), but only 10% for two components (e.g., modeling skills). Regarding treatment receipt, most participants completed all homework. Knowledge and skills mastery was high (mostly >85%). In program evaluations, 93% indicated the program helped them cope with breast cancer "quite a bit/extremely." Participants reported improved self-management skills and knowledge. Suggested improvements were to add more sessions to practice cognitive-behavioral coping skills and simplify exercises and homework. We conclude that CBSM programs can be delivered in community settings by trained peers with high fidelity, acceptability, and perceived usefulness. Results provided some areas where the program could be improved. Our rigorous evaluation illustrates methods for evaluating processes of translating EBIs for community implementation.

Trial Registration: NCT01383174 (ClinicalTrials.gov).
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http://dx.doi.org/10.1007/s13187-017-1202-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5591043PMC
August 2018

Development of a survey instrument to measure patient experience of integrated care.

BMC Health Serv Res 2016 06 1;16:193. Epub 2016 Jun 1.

Department of Family and Community Medicine, University of California-San Francisco, San Francisco, CA, USA.

Background: Healthcare systems are working to move towards more integrated, patient-centered care. This study describes the development and testing of a multidimensional self-report measure of patients' experiences of integrated care.

Methods: Random-digit-dial telephone survey in 2012 of 317 adults aged 40 years or older in the San Francisco region who had used healthcare at least twice in the past 12 months. One-time cross-sectional survey; psychometric evaluation to confirm dimensions and create multi-item scales. Survey data were analyzed using VARCLUS and confirmatory factor analysis and internal consistency reliability testing.

Results: Scales measuring five domains were confirmed: coordination within and between care teams, navigation (arranging appointments and visits), communication between specialist and primary care doctor, and communication between primary care doctor and specialist. Four of these demonstrated excellent internal consistency reliability. Mean scale scores indicated low levels of integration.

Conclusion: These scales measuring integrated care capture meaningful domains of patients' experiences of health care. The low levels of care integration reported by patients in the study sample suggest that these types of measures should be considered in ongoing evaluations of health system performance and improvement. Further research should examine whether differences in patient experience of integrated care are associated with differences in the processes and outcomes of care received.
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http://dx.doi.org/10.1186/s12913-016-1437-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890282PMC
June 2016

Development of the Stress of Immigration Survey: A Field Test Among Mexican Immigrant Women.

Fam Community Health 2016 Jan-Mar;39(1):40-52

School of Nursing, University of California San Francisco, San Francisco, California (Dr Sternberg); UCSF Department of Medicine, San Francisco, California (Drs Nápoles and Gregorich); UCSF School of Nursing (Drs Paul and Lee); UCSF Institute of Health and Aging (Dr Stewart).

The Stress of Immigration Survey (SOIS) is a screening tool used to assess immigration-related stress. The mixed methods approach included concept development, pretesting, field testing, and psychometric evaluation in a sample of 131 low-income women of Mexican descent. The 21-item SOIS screens for stress related to language, immigrant status, work issues, yearning for family and home country, and cultural dissonance. Mean scores ranged from 3.6 to 4.4 (a scale of 1-5, higher is more stress). Cronbach α values were more than 0.80 for all subscales. The SOIS may be a useful screening tool for detecting high levels of immigration-related stress in low-income Mexican immigrant women.
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http://dx.doi.org/10.1097/FCH.0000000000000088DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4747418PMC
July 2016

Study protocol for a cluster randomized trial of the Community of Voices choir intervention to promote the health and well-being of diverse older adults.

BMC Public Health 2015 Oct 13;15:1049. Epub 2015 Oct 13.

Center for Aging in Diverse Communities, University of California, San Francisco, USA.

Background: Older adults are the fastest growing segment of the United States population. There is an immediate need to identify novel, cost-effective community-based approaches that promote health and well-being for older adults, particularly those from diverse racial/ethnic and socioeconomic backgrounds. Because choral singing is multi-modal (requires cognitive, physical, and psychosocial engagement), it has the potential to improve health outcomes across several dimensions to help older adults remain active and independent. The purpose of this study is to examine the effect of a community choir program (Community of Voices) on health and well-being and to examine its costs and cost-effectiveness in a large sample of diverse, community-dwelling older adults.

Method/design: In this cluster randomized controlled trial, diverse adults age 60 and older were enrolled at Administration on Aging-supported senior centers and completed baseline assessments. The senior centers were randomly assigned to either start the choir immediately (intervention group) or wait 6 months to start (control). Community of Voices is a culturally tailored choir program delivered at the senior centers by professional music conductors that reflects three components of engagement (cognitive, physical, and psychosocial). We describe the nature of the study including the cluster randomized trial study design, sampling frame, sample size calculation, methods of recruitment and assessment, and primary and secondary outcomes.

Discussion: The study involves conducting a randomized trial of an intervention as delivered in "real-world" settings. The choir program was designed using a novel translational approach that integrated evidence-based research on the benefits of singing for older adults, community best practices related to community choirs for older adults, and the perspective of the participating communities. The practicality and relatively low cost of the choir intervention means it can be incorporated into a variety of community settings and adapted to diverse cultures and languages. If successful, this program will be a practical and acceptable community-based approach for promoting health and well-being of older adults.

Trial Registration: ClinicalTrials.gov NCT01869179 registered 9 January 2013.
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http://dx.doi.org/10.1186/s12889-015-2395-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603966PMC
October 2015

Nuevo Amanecer: results of a randomized controlled trial of a community-based, peer-delivered stress management intervention to improve quality of life in Latinas with breast cancer.

Am J Public Health 2015 Jul 23;105 Suppl 3:e55-63. Epub 2015 Apr 23.

Anna María Nápoles, Jasmine Santoyo-Olsson, and Steven Gregorich are with the Department of Medicine, Division of General Internal Medicine, University of California, San Francisco. Carmen Ortíz is with Círculo de Vida Cancer Support and Resource Center, San Francisco, CA. Anita L. Stewart is with the Institute for Health and Aging at the University of California, San Francisco. At the time of the study, Howard E. Lee was with the San Mateo Medical Center, San Mateo, CA. Ysabel Durón is with Latinas Contra Cancer, San José, CA. Peggy McGuire is with the Women's Cancer Resource Center, Oakland, CA. Judith Luce is with San Francisco General Hospital, San Francisco, CA.

Objectives: We evaluated a community-based, translational stress management program to improve health-related quality of life in Spanish-speaking Latinas with breast cancer.

Methods: We adapted a cognitive-behavioral stress management program integrating evidence-based and community best practices to address the needs of Latinas with breast cancer. Spanish-speaking Latinas with breast cancer were randomly assigned to an intervention or usual-care control group. Trained peers delivered the 8-week intervention between February 2011 and February 2014. Primary outcomes were breast cancer-specific quality of life and distress, and general symptoms of distress.

Results: Of 151 participants, 95% were retained at 6 months (between May 2011 and May 2014). Improvements in quality of life from baseline to 6 months were greater for the intervention than the control group on physical well-being, emotional well-being, breast cancer concerns, and overall quality of life. Decreases from baseline to 6 months were greater for the intervention group on depression and somatization.

Conclusions: Results suggest that translation of evidence-based programs can reduce psychosocial health disparities in Latinas with breast cancer. Integration of this program into community-based organizations enhances its dissemination potential.
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http://dx.doi.org/10.2105/AJPH.2015.302598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455521PMC
July 2015

Physician counseling on colorectal cancer screening and receipt of screening among Latino patients.

J Gen Intern Med 2015 Apr;30(4):483-9

Division of General Internal Medicine, Department of Medicine, and Medical Effectiveness Research Center for Diverse Populations, University of California San Francisco (UCSF), 3333 California Street, Suite 335, San Francisco, CA, 94118-0856, USA,

Background: Latinos have lower rates of colorectal cancer (CRC) screening and later stage diagnosis than Whites, which may be partially explained by physician communication factors.

Objective: We assessed associations between patient-reported physician counseling regarding CRC screening and receipt of CRC screening among Latino primary care patients.

Design: This was a cross-sectional telephone survey.

Participants: The participants of this study were Latino primary care patients 50 years of age or older, with one or more visits during the preceding year.

Main Measures: We developed patient-reported measures to assess whether physicians provided explanations of CRC risks and tests, elicited patients' barriers to CRC screening, were responsive to patients' concerns about screening, and encouraged patients to be screened. Outcomes were patient reports of receipt of endoscopy (sigmoidoscopy or colonoscopy) and fecal occult blood test (FOBT) within recommended guidelines.

Key Results: Of 817 eligible patients contacted, 505 (62 %) completed the survey; mean age was 61 years (SD 8.4), 69 % were women, and 53 % had less than high school education. Forty-six percent reported obtaining endoscopy (with or without FOBT), 13 % reported FOBT only, and 41 % reported no CRC screening. In bivariate analyses, physician explanations, elicitation of barriers, responsiveness to concerns, and greater encouragement for screening were associated with receipt of endoscopy (p < 0.001), and explanations (p < 0.05) and encouragement (p < 0.001) were associated with FOBT. Adjusting for covariates, physician explanations (OR = 1.27; 95 % CI 1.03, 1.58) and greater physician encouragement (OR = 6.74; 95 % CI 3.57, 12.72) were associated with endoscopy; patients reporting quite a bit/a lot of physician encouragement had six times higher odds of obtaining the FOBT as those reporting none/a little encouragement (OR = 6.54; 95 % CI 2.76, 15.48).

Conclusions: Among primarily lower-socioeconomic status Latino patients, the degree to which patients perceived that physicians encouraged CRC screening was more strongly associated with screening than with providing risk information, eliciting barriers, and responding to their concerns about screening.
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http://dx.doi.org/10.1007/s11606-014-3126-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4370980PMC
April 2015

Defining novel health-related quality of life domains in lung transplantation: a qualitative analysis.

Qual Life Res 2015 Jun 4;24(6):1521-33. Epub 2014 Dec 4.

Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, 350 Parnassus Avenue, Suite 609, San Francisco, CA, 94117, USA,

Purpose: Health-related quality of life (HRQL) domains vary across disease conditions and are determined by standards, values, and priorities internal to patients. Although the clinical goals of lung transplantation are to improve patient survival and HRQL, what defines HRQL in lung transplantation is unknown. Employing a qualitative approach, we aimed to identify HRQL domains important in lung transplantation.

Methods: We conducted semi-structured interviews in purposefully sampled lung transplant recipients (n = 8) representing a spectrum of ages, gender, indications for transplantation, and time since transplantation as well as healthcare practitioners representing a spectrum of practitioner types (n = 9). Grounded theory was used to identify HRQL domains important in lung transplantation, building on but going beyond domains already defined in the SF-36, the most commonly used instrument in this population.

Results: In addition to confirming the relevance of the eight SF-36 domains, we identified 11 novel HRQL domains. Palliation of respiratory symptoms was identified as important. After transplant surgery, new HRQL domains emerged including: distressing symptoms spanning multiple organ systems, worry about infection and acute rejection, treatment burden, and depression. Further, patients identified challenges to intimacy, changes in social relationships, and problems with cognitive functioning. Saliently, worry about limited life expectancy was pervasive and impaired life planning.

Conclusions: We found that HRQL in lung transplantation is defined by both generic and transplant-specific domains. Delineating and refining these domains can inform efforts to improve clinical outcomes and HRQL measurement in lung transplantation.
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http://dx.doi.org/10.1007/s11136-014-0875-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4456337PMC
June 2015

Day-to-Day Impact of Vaginal Aging questionnaire: a multidimensional measure of the impact of vaginal symptoms on functioning and well-being in postmenopausal women.

Menopause 2015 Feb;22(2):144-54

From the Departments of 1Medicine and 2Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, CA; 3Division of Research, Kaiser Permanente, Oakland, CA; 4Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL; and 5Department of Family and Community Medicine and 6Institute of Health and Aging, University of California San Francisco, San Francisco, CA.

Objective: This study aims to develop a self-report questionnaire assessing the impact of vaginal dryness, soreness, itching, irritation, and pain on functioning and well-being in postmenopausal women.

Methods: Structured self-report items were developed to address the impact of vaginal symptoms on functioning and well-being based on findings from focus groups with racially/ethnically diverse, symptomatic postmenopausal women. Items were refined after cognitive interview pretesting and field-tested among symptomatic postmenopausal women enrolled in a multiethnic cohort study in California. Exploratory factor analysis (SAS PROC VARCLUS) and confirmatory factor analysis evaluated factor structure and eliminated poorly fitting items. Additional evidence of construct validity was obtained via examination of correlations with other measures of related constructs. Internal consistency and test-retest reliability were assessed using Cronbach α and correlation coefficients, respectively.

Results: For the 745 postmenopausal women who completed the draft questionnaire, the mean (SD) age was 56.2 (8.5) years, and 66% of the respondents were racial/ethnic minorities. The refined questionnaire included four multi-item scales addressing symptom impact on (1) activities of daily living, (2) emotional well-being, (3) sexual functioning, and (4) self-concept and body image. The four-factor model provided good approximate fit (comparative fit index, 0.987; standardized root-mean-square residual, 0.038). Correlations with other measures of symptom bothersomeness, sexual function, depression, and anxiety conformed to hypotheses. Cronbach α values ranged from 0.82 to 0.93. Intraclass coefficients ranged from 0.47 to 0.72.

Conclusions: The Day-to-Day Impact of Vaginal Aging questionnaire is a new multidimensional self-report measure designed to facilitate evaluation of the impact of vaginal symptoms on postmenopausal women of diverse backgrounds.
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http://dx.doi.org/10.1097/GME.0000000000000281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4280352PMC
February 2015

Maternal acculturation and the prenatal care experience.

J Womens Health (Larchmt) 2014 Aug 30;23(8):688-706. Epub 2014 Jun 30.

1 Department of Pediatrics and Epidemiology and Biostatistics, University of California , San Francisco, San Francisco, California.

Background: Acculturation may influence women's perceptions of health care experiences and may explain the epidemiologic paradox, whereby foreign-born women have lower rates of adverse birth outcomes than United States (US)-born women. We evaluated the relationship between maternal acculturation and specific dimensions of prenatal interpersonal processes of care (IPC) in ethnically diverse women.

Methods: Cross-sectional analysis of 1243 multiethnic, postpartum women who delivered at Kaiser Permanente Medical Center in Walnut Creek or San Francisco General Hospital. Women retrospectively reported on their experiences in seven domains of IPC during their pregnancy pertaining to communication, decision making, and interpersonal style. The primary independent variables were four measures of maternal acculturation: birthplace, English language proficiency, the number of years residing in the US, and age at immigration to the US. Generalized linear models, stratified by infant outcome, measured the association between each maternal acculturation measure and specific IPC domains while adjusting for type of health insurance, demographic, and reproductive factors.

Results: Approximately 60% of the sample was foreign-born, 36% reported low English proficiency, 43% had resided in the US <10 years, and 35% were age 20 years or older when they immigrated to the US. Over 64% of the women reported having public insurance during pregnancy. In adjusted analyses among women who delivered term and normal birth weight infants, less acculturated women and women with non-private health insurance were more likely to have higher mean IPC scores when compared to more acculturated or US-born women and women with private health insurance, respectively.

Conclusion: In a large and ethnically diverse sample of childbearing women in Northern California, less acculturated pregnant women reported better prenatal care experiences than more acculturated and US-born women, another dimension of the "epidemiologic paradox." However, the relationship between acculturation and IPC, as reported during the postpartum period, differed according to infant outcomes.
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http://dx.doi.org/10.1089/jwh.2013.4585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129971PMC
August 2014