Publications by authors named "Natalie Guerrero"

11 Publications

  • Page 1 of 1

Prolonged Untreated Disease and Limited English Proficiency: A Case of Van Wyk-Grumbach Syndrome.

J Adolesc Health 2020 Nov 18. Epub 2020 Nov 18.

Section of Adolescent Medicine and Sports Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.

Children from families with limited English proficiency have worse health outcomes than those from English-speaking families, likely related to the impact of a variety of social determinants on an increased risk of delayed presentation, diagnosis, and loss to follow-up. Van Wyk-Grumbach syndrome (VWGS) is a result of prolonged untreated primary hypothyroidism and early diagnosis of hypothyroidism is critical to prevent VWGS from developing. Whether social determinants of health, particularly limited English proficiency, impact the development, diagnosis, and treatment of VWGS has not been discussed previously. Here, we describe the case of an adolescent girl diagnosed with VWGS whose primary caregiver is foreign-born and with limited English proficiency, explore factors that may have placed her at increased risk for delayed presentation of VWGS, and discuss ongoing challenges of her disease management. We briefly review the pathophysiology of VWGS, emphasize the importance of being sensitive to this atypical presentation of hypothyroidism, and explore the intersections of this case with limited English proficiency status.
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November 2020

The Association Between Exposure to Maternal Depression During Year 2 of a Child's Life and Future Child Problem Behavior.

Matern Child Health J 2020 Nov 13. Epub 2020 Nov 13.

Departments of Population Health and Internal Medicine, Dell Medical School, University of Texas At Austin, Austin, TX, USA.

Introduction: We examined the association of exposure to maternal depression during year 2 of a child's life with future child problem behavior. We conducted a secondary analysis to investigate whether race/ethnicity is a moderator of this relationship.

Methods: We used Fragile Families and Child Well-Being Study data (age 3 N = 3288 and 49% Black, 26% Hispanic, 22% non-Hispanic White; age 5 N = 3001 and 51% Black, 25% Hispanic, 21% non-Hispanic White; age 9 N = 3630 and 50% Black, 25% Hispanic, 21% non-Hispanic White) and ordinal logistic regression to model problem behavior at ages 3, 5, and 9 on maternal depression status during year 2.

Results: At age 9, children whose mother was depressed during year 2 were significantly more likely to have higher internalizing (AOR = 1.92, 95% CI: 1.42,2.61) and externalizing (AOR = 1.65, 95% CI: 1.10,2.48) problem behavior scores. In our secondary analysis, race/ethnicity did not have moderating effects, potentially due to a limitation of the data that required use of maternal self-reported race/ethnicity as a proxy for child race/ethnicity.

Discussion: Exposure to maternal depression after the prenatal and perinatal periods may have a negative association with children's behavioral development through age 9. Interventions that directly target maternal depression during this time should be developed. Additional research is needed to further elucidate the role of race/ethnicity in the relationship between maternal depression and child problem behavior.
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November 2020

Food Insecurity and Housing Instability Partially Mediate the Association Between Maternal Depression and Child Problem Behavior.

J Prim Prev 2020 06;41(3):245-259

Departments of Population Health Sciences and Medicine, Dell Medical School, University of Texas at Austin, Austin, USA.

Maternal depression is a risk factor for the development of problem behavior in children. Although food insecurity and housing instability are associated with adult depression and child behavior, how these economic factors mediate or moderate the relationship between maternal depression and child problem behavior is not understood. The purpose of this study was to determine whether food insecurity and housing instability are mediators and/or moderators of the relationship between maternal depression when children are age 3 and children's problem behaviors at age 9 and to determine whether these mechanisms differ by race/ethnicity. We used data from the Fragile Families and Child Wellbeing Study. Food insecurity and housing instability at age 5 were tested as potential mediators and moderators of the relationship between maternal depression status at age 3 and problem behavior at age 9. A path analysis confirmed our hypothesis that food insecurity and housing instability partially mediate the relationship between maternal depression when children are age 3 and problem behavior at age 9. However, housing instability was only a mediator for externalizing problem behavior and not internalizing problem behavior or overall problem behavior. Results of the moderation analysis suggest that neither food insecurity nor housing instability were moderators. None of the mechanisms explored differed by race/ethnicity. While our findings stress the continued need for interventions that address child food insecurity, they emphasize the importance of interventions that address maternal mental health throughout a child's life. Given the central role of maternal health in child development, additional efforts should be made to target maternal depression.
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June 2020

Physician perceptions of the types of roles interpreters play in limited English proficient pediatric encounters and how they evaluate the quality of interpretation.

Prim Health Care Res Dev 2019 03 20;20:e25. Epub 2019 Mar 20.

Professor of Medicine and Population Health Sciences, Departments of Medicine and Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.

Purpose: The purpose of this study is to understand different roles that interpreters play in a pediatric, limited English proficient (LEP) health care encounter and to describe what factors within each role inform physicians' assessment of the overall quality of interpretation.

Background: Language barriers contribute to lower quality of care in LEP pediatric patients compared to their English-speaking counterparts. Use of professional medical interpreters has been shown to improve communication and decrease medical errors in pediatric LEP patients. In addition, in many pediatric encounters, interpreters take on roles beyond that of a pure language conduit.

Methods: We conducted 11 semi-structured interviews with pediatricians and family medicine physicians in one health system. Transcripts were audio-recorded and transcribed verbatim. We analyzed our data using directed content analysis. Two study team members coded all transcripts, reviewed agreement, and resolved discrepancies.

Findings: Physicians described four different interpreter roles: language conduit, flow manager, relationship builder, and cultural insider. Within each role, physicians described components of quality that informed their assessment of the overall quality of interpretation during a pediatric encounter. We found that for many physicians, a high-quality interpreted encounter involves multiple roles beyond language transmission. It is important for health care systems to understand how health care staff conceptualize these relationships so that they can develop appropriate expectations and trainings for medical interpreters in order to improve health outcomes in pediatric LEP patients.
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March 2019

Informing physician strategies to overcome language barriers in encounters with pediatric patients.

Patient Educ Couns 2018 04 15;101(4):653-658. Epub 2017 Nov 15.

Departments of Medicine and Population Health, Dell Medical School, Unversity of Texas-Austin, Austin, TX, USA. Electronic address:

Objectives: To describe physician perceptions of differences in limited English proficient (LEP) pediatric encounters and the behavioral adaptations they make to provide quality care to LEP pediatric patients.

Methods: We conducted 30min, semi-structured interviews with 6 family physicians and 5 pediatricians in one health system. Audiotapes from each interview were transcribed verbatim then coded using content analysis.

Results: Multiple aspects of the LEP pediatric encounter were perceived by physicians as different from other encounters: trust and relationship between physician and LEP child/child's family, continuity of care, encounter's structure and flow, patient assessment, and communication barriers. Within each of these themes, physicians identified how they adapt their behavior to improve the quality of care provided to LEP children and families.

Conclusions: Physicians' made both positive and negative adaptations in LEP pediatric encounters that may impact the quality of care provided to these patients.

Practice Implications: By identification of specific positive and negative behavioral adaptations, this study emphasizes intervention targets, such as demonstrating interest in an LEP pediatric patient's family story and individuality and using common niceties in conversations with LEP children.
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April 2018

Cervical and Breast Cancer Screening Among Mexican Migrant Women, 2013.

Prev Chronic Dis 2016 08 11;13:E104. Epub 2016 Aug 11.

Dornsife School of Public Health, Drexel University, 3215 Market St, Nesbitt Hall 458, Philadelphia, PA 19104. Email:

Introduction: Information on cervical and breast cancer screening among Latinas in the United States is limited. Even less information is available on screening practices of migrant women who engage in circular migration. We examined rates of cervical and breast cancer screening and the extent to which sociodemographics and other characteristics explain screening practices of Mexican migrant women who return to Mexico from the United States.

Methods: We used data from a cross-sectional probability survey of Mexico-born migrant women who returned, through Tijuana, to Mexico from the United States in 2013. The sample consisted of women who returned involuntarily (via deportation) or voluntarily; 177 reported authorized documentation status, and 36 reported unauthorized documentation status in the previous 12 months. Descriptive statistics were calculated and logistic regressions were estimated.

Results: Of 36 undocumented migrant women, 8 (22.2%) had a Papanicolaou test and 11 (30.6%) had a mammogram in the previous year; of 177 documented migrants, 83 (46.9%) had a Papanicolaou test and 68 (38.4%) had a mammogram. Undocumented migrants were less likely than documented migrants to receive a Papanicolaou test (odds ratio [OR] = 0.29; 95% confidence interval [CI], 0.12-0.67); the likelihood was similar after adjustment for sociodemographic, migration, and acculturation factors (adjusted OR = 0.33; 95% CI, 0.12-0.90). Having health insurance (adjusted OR = 4.17; 95% CI, 1.80-9.65) and a regular source of health care (adjusted OR = 2.83; 95% CI, 1.05-7.65) were significant predictors of receiving a mammogram but not a Papanicolaou test.

Conclusion: Public health programs are needed to improve access to cervical and breast cancer screenings for Latina migrant women in general and undocumented circular migrants in particular.
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August 2016

Community-based restaurant interventions to promote healthy eating: a systematic review.

Prev Chronic Dis 2015 May 21;12:E78. Epub 2015 May 21.

610 Walnut St, 605 WARF, Madison, WI 53705, Email:

Introduction: Eating in restaurants is associated with high caloric intake. This review summarizes and evaluates the evidence supporting community-based restaurant interventions.

Methods: We searched all years of PubMed and Web of Knowledge through January 2014 for original articles describing or evaluating community-based restaurant interventions to promote healthy eating. We extracted summary information and classified the interventions into 9 categories according to the strategies implemented. A scoring system was adapted to evaluate the evidence, assigning 0 to 3 points to each intervention for study design, public awareness, and effectiveness. The average values were summed and then multiplied by 1 to 3 points, according to the volume of research available for each category. These summary scores were used to determine the level of evidence (insufficient, sufficient, or strong) supporting the effectiveness of each category.

Results: This review included 27 interventions described in 25 studies published since 1979. Most interventions took place in exclusively urban areas of the United States, either in the West or the South. The most common intervention categories were the use of point-of-purchase information with promotion and communication (n = 6), and point-of-purchase information with increased availability of healthy choices (n = 6). Only the latter category had sufficient evidence. The remaining 8 categories had insufficient evidence because of interventions showing no, minimal, or mixed findings; limited reporting of awareness and effectiveness; low volume of research; or weak study designs. No intervention reported an average negative impact on outcomes.

Conclusion: Evidence about effective community-based strategies to promote healthy eating in restaurants is limited, especially for interventions in rural areas. To expand the evidence base, more studies should be conducted using robust study designs, standardized evaluation methods, and measures of sales, behavior, and health outcomes.
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May 2015

Determinants of trust in health care in an older population.

J Am Geriatr Soc 2015 Mar 6;63(3):553-7. Epub 2015 Mar 6.

School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.

Objectives: To explore differences in sociodemographic and psychological correlates of institutional trust in health care in an aging population of African Americans and non-Hispanic whites.

Design: Cross-sectional survey data from the longitudinal Chicago Health and Aging Project.

Setting: Population-based study of three communities in the Chicago area.

Participants: African Americans (n=2,284) and non-Hispanic whites (1,354) with a mean age of 79.3.

Measurements: Demographic factors, socioeconomic status (SES), healthcare access, cynical hostility, perceived discrimination, depression, and institutional trust in health care.

Results: African Americans reported substantially lower healthcare trust than non-Hispanic whites (P<.001). After adjustment for demographic variables and SES, only race (P<.001) and age (P=.008) were significantly associated with healthcare trust scores. The association between race and healthcare trust was slightly attenuated after adjusting for cynical hostility, depressive symptoms, and perceived discrimination (P<.001). Each of these variables was negatively associated with healthcare trust, and together these accounted for approximately 15% of racial differences in healthcare trust.

Conclusion: Psychological factors, not demographic characteristics, SES, or healthcare factors, appear to contribute the most to disparities in healthcare trust between older African Americans and non-Hispanic whites.
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March 2015

Urban-rural and regional variability in the prevalence of food insecurity: the survey of the health of Wisconsin.

WMJ 2014 Aug;113(4):133-8

Background: Food insecurity is a public health concern estimated to affect 18 million American households nationally, which can result in chronic nutritional deficiencies and other health risks. The relationships between food insecurity and specific demographic and geographic factors in Wisconsin are not well documented. The goals of this paper are to investigate sociodemographic and geographic features associated with food insecurity in a representative sample of Wisconsin adults.

Methods: This study used data from the Survey of the Health of Wisconsin (SHOW). SHOW annually collects health-related data on a representative sample of Wisconsin residents. Between 2008-2012, 2,947 participants were enrolled in the SHOW study. The presence of food insecurity was defined based on the participant's affirmative answer to the question "In the last 12 months, have you been concerned about having enough food for you or your family?"

Results: After adjustment for age, race, and gender, 13.2% (95% CI, 10.8%-15.1%) of participants reported food insecurity, 56.7% (95% CI, 50.6%-62.7%) of whom were female. Food insecurity did not statistically differ by region (P = 0.30). The adjusted prevalence of food insecurity in the urban core, other urban, and rural areas was 14.1%, 6.5%, and 10.5%, respectively. These differences were not statistically significant (P = 0.13) and, for urban core and rural areas, persisted even when accounting for level of economic hardship in the community.

Conclusions: The prevalence of food insecurity is substantial, affecting an estimated 740,000 or more Wisconsin residents. The prevalence was similarly high in all urbanicity levels and across all state public health regions in Wisconsin. Food insecurity is a common problem with potentially serious health consequences affecting populations across the entire state.
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August 2014

Factors influencing the degradation of archival formalin-fixed paraffin-embedded tissue sections.

J Histochem Cytochem 2011 Apr 10;59(4):356-65. Epub 2011 Feb 10.

Tissue Array Research Program, Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA.

The loss of antigenicity in archival formalin-fixed paraffin-embedded (FFPE) tissue sections negatively affects both diagnostic histopathology and advanced molecular studies. The mechanisms underlying antigenicity loss in FFPE tissues remain unclear. The authors hypothesize that water is a crucial contributor to protein degradation and decrement of immunoreactivity in FFPE tissues. To test their hypothesis, they examined fixation time, processing time, and humidity of storage environment on protein integrity and antigenicity by immunohistochemistry, Western blotting, and protein extraction. This study revealed that inadequate tissue processing, resulting in retention of endogenous water in tissue sections, results in antigen degradation. Exposure to high humidity during storage results in significant protein degradation and reduced immunoreactivity, and the effects of storage humidity are temperature dependent. Slides stored under vacuum with desiccant do not protect against the effects of residual water from inadequate tissue processing. These results support that the presence of water, both endogenously and exogenously, plays a central role in antigenicity loss. Optimal tissue processing is essential. The parameters of optimal storage of unstained slides remain to be defined, as they are directly affected by preanalytic variables. Nevertheless, minimization of exposure to water is required for antigen preservation in FFPE tissue sections.
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April 2011

Factors in tissue handling and processing that impact RNA obtained from formalin-fixed, paraffin-embedded tissue.

J Histochem Cytochem 2008 Nov 18;56(11):1033-42. Epub 2008 Aug 18.

Tissue Array Research Program, Laboratory of Pathology, National Institutes of Health, Bethesda, Maryland, USA.

Formalin-fixed, paraffin-embedded (FFPE) tissue is the most common specimen available for molecular assays on tissue after diagnostic histopathological examination. RNA from FFPE tissue suffers from strand breakage and cross-linking. Despite excellent extraction methods, RNA quality from FFPE material remains variable. To address the RNA quality factors within FFPE tissues, we studied RNA quality, isolating individual elements of the tissue fixation and processing including length of fixation in formalin and the type of buffer incorporated in the fixative. We examined the impact of the length of the tissue processing cycle as well. The optimal fixation period of 12-24 hr in phosphate-buffered formalin resulted in better-quality RNA. Longer tissue processing times were associated with higher quality RNA. We determined that the middle region of gene suffers less damage by these processes as shown by real-time quantitative RT-PCR. These data provide key information for the development of methods of analysis of gene expression in archival FFPE tissues and contribute to the establishment of objective standards for the processing and handling of tissue in surgical pathology. This manuscript contains online supplemental material at Please visit this article online to view these materials.
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November 2008