ObjectiveThe intent of the study was to develop and validate a comparable health literacy test for Spanish-speaking and English-speaking populations.Study DesignThe design of the instrument, named the Short Assessment of Health Literacy-Spanish and English (SAHL-S&E), combined a word recognition test, as appearing in the Rapid Estimate of Adult Literacy in Medicine (REALM), and a comprehension test using multiple-choice questions designed by an expert panel. We used the item response theory (IRT) in developing and validating the instrument.Data CollectionValidation of SAHL-S&E involved testing and comparing the instrument with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at the University of North Carolina Healthcare System.Principal FindingsBased on IRT analysis, 18 items were retained in the comparable test. The Spanish version of the test, SAHL-S, was highly correlated with other Spanish health literacy instruments, Short Assessment of Health Literacy for Spanish-Speaking Adults (r=0.88, p <.05) and the Spanish Test of Functional Health Literacy in Adults (TOFHLA) (r=0.62, p <.05). The English version, SAHL-E, had high correlations with REALM (r=0.94, p <.05) and the English TOFHLA (r=0.68, p <.05). Significant correlations were found between SAHL-S&E and years of schooling in both Spanish- and English-speaking samples (r=0.15 and 0.39, respectively). SAHL-S&E displayed satisfactory reliability of 0.80 and 0.89 in the Spanish- and English-speaking samples, respectively. IRT analysis indicated that the SAHL-S&E score was highly reliable for individuals with a low level of health literacy.ConclusionsThe new instrument, SAHL-S&E, has good reliability and validity. It is particularly useful for identifying individuals with low health literacy and could be used to screen for low health literacy among Spanish and English speakers.

Objective: The objectives Of this Study were: (1) to investigate what predisposing, enabling, and need factors are related to the purchase of medicines from "tiendas" and other countries and (2) to describe who Latinos typically receive medication information from in the United States and their home Countries. In the United States, Latino grocery stores are referred to as "tiendas".Methods: Individuals were eligible to participate if they: were age 18 and over, self-identified as being Latino, and they or their children were Currently taking prescription medications. Ninety-three individuals were interviewed in Spanish.Results: Forty-two percent of participants reported purchasing medicine in "tiendas" but only 5.4% reported that "tiendas" were their usual source of medicine. Ninety-one percent of individuals used U.S. pharmacies as their Usual Source of medicines. Individuals with health insurance were significantly less likely to have purchased medicine at a "tienda" (odds ratio = 0.16, 95% confidence interval = 0.03, 0.86). Thirty percent of individuals reported buying medicines in another country to bring back to the U.S. for their use. The most commonly Purchased medicines included: antibiotics, vitamins, pain medicine, and herbal medicine. The Latinos in this sample preferred to receive verbal information about medications from their physicians (75.3%) followed by pharmacists (16.1%).Conclusion: Despite the fact that the overwhelming majority of Latino patients reported using. pharmacies as their usual source of medication, many participants reported having purchased medications from "tiendas" and other Countries.Practice implications: Providers need to make sure to ask patients from all ethnic backgrounds about all medicines they are taking, especially those purchased in "tiendas" or other countries. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

OBJECTIVES:To examine (1) Latino patients' language preferences for receiving verbal and written medication information in community pharmacies, (2) the types of problems and concerns Latino patients report about using their medications, and (3) the factors that Latino patients believe are important when choosing a community pharmacy.METHODS:Individuals were eligible to participate if they were 18 years of age or older, if they self-identified as being Latino, and if they or their children were currently taking prescription medications. All 93 participating individuals were interviewed in Spanish.RESULTS:The majority of patients did not always receive their prescription labels or written medication information in Spanish. Approximately 52% of the respondents preferred to receive verbal information in Spanish without an interpreter, and 21.5% preferred to receive it in Spanish with an interpreter. Most respondents (70%) preferred written information in Spanish, and 21.5% preferred written information in both Spanish and English. The most commonly reported problems were difficulty paying for medications, difficulty reading the English on the prescription labels, and adverse effects. Participants valued pharmacies with friendly and respectful employees.CONCLUSION:Study participants reported many problems or concerns in using their medications, and the majority preferred receiving written and verbal information about their medication in Spanish. Pharmacies need to find better ways of providing services to the rapidly growing Latino population.

Latino children use fewer professional dental services and experience more dental decay than non-Hispanic White and non-Hispanic Black children. This study tested the association between four types of social support (information, influence, material aid, emotional aid) and dental use among children of Latina immigrants in North Carolina. Latina mothers age 15–44 years (N=174) were sampled from four counties using a multistage church-based sampling design. Each mother reported dental care use for her oldest child younger than 11 years of age. Instrumental aid (information) alone was not associated with dental care use, but receiving any of the other types of social support was associated with dental care use at the bivariate level (p<.01) and at the multivariate level (OR = 3.13; 95% CI = 1.67–5.87). Over half of the women (65.2%) received at least one of these forms of social support. Interventions expanding dental-related social support could help Latina immigrant mothers overcome barriers to dental care for their children.

Surveys are sometimes used to assess women's perceptions of the quality of reproductive health care, but less empowered women may feel uncomfortable expressing their views in this method. We demonstrate the use of a participatory approach, combining a standard survey with an innovative photonarrative method. Women in Cochabamba, Bolivia, were asked to participate in exit surveys (n = 108). A subsample did photonarratives (n = 20). The survey showed rural women had less access to care, but photonarratives revealed the cause—fear. Women asserted quality of care was high, but photonarratives contradicted survey results. Staff used photonarratives to select action items for quality improvement.

Objective: This study aims to develop and pilot test a dental word recognition instrument. Methods: The development of our instrument was based on the Rapid Estimate of Adult Literacy in Medicine (REALM), an efficient word recognition instrument used to assess health literacy in the medical arena. Our instrument, Rapid Estimate of Adult Literacy in Dentistry (REALD-30), consisted of 30 common dental words with various degrees of difficulty. It was administered to 202 English-speaking adults recruited from outpatient medical clinics. We examined the instrument's internal reliability using Cronbach's alpha and its validity by correlating the REALD-30 score to two dental outcomes (perceived dental health status and oral health-related quality of life) and medical health literacy. Results: REALD-30 scores were significantly correlated with REALM scores. REALD-30 was significantly related to perceived dental health status in the bivariate analysis. It also was significantly related to oral health-related quality of life in a multivariate analysis. In contrast, medical health literacy was not related to either of the dental outcome measures. Conclusions: The new REALD-30 instrument displays good reliability but only partial validity. Results suggest that dental health literacy may be distinct from medical health literacy and may have an independent effect on dental health outcomes.

Some health indicators for Latinos tend to be more positive than socioeconomic status would predict. Yet, Latina women and their young children use fewer preventive health services and have a higher incidence of preventable diseases than non-Hispanic whites. The Institute of Medicine recently called for intervention research among minority subgroups to end racial and ethnic disparities in health care. To help guide future intervention research, this article presents a critique and synthesis of the peer-reviewed literature on interventions that enroll Latina women into preventive reproductive health services (prenatal care, cervical cancer screening, and child immunizations). Results are presented according to three categories of interventions: improvements within formal health care settings, outreach through lay health advisors (promotoras) and media, and interventions combining these approaches. An agenda for intervention research is proposed for preventive-care use by this population.

OBJECTIVE:The study was intended to develop and validate a health literacy test, termed the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), for the Spanish-speaking population.STUDY DESIGN:The design of SAHLSA was based on the Rapid Estimate of Adult Literacy in Medicine (REALM), known as the most easily administered tool for assessing health literacy in English. In addition to the word recognition test in REALM, SAHLSA incorporates a comprehension test using multiple-choice questions designed by an expert panel.DATA COLLECTION:Validation of SAHLSA involved testing and comparing the tool with other health literacy instruments in a sample of 201 Spanish-speaking and 202 English-speaking subjects recruited from the Ambulatory Care Center at UNC Health Care.PRINCIPAL FINDINGS:With only the word recognition test, REALM could not differentiate the level of health literacy in Spanish. The SAHLSA significantly improved the differentiation. Item response theory analysis was performed to calibrate the SAHLSA and reduce the instrument to 50 items. The resulting instrument, SAHLSA-50, was correlated with the Test of Functional Health Literacy in Adults, another health literacy instrument, at r=0.65. The SAHLSA-50 score was significantly and positively associated with the physical health status of Spanish-speaking subjects (p<.05), holding constant age and years of education. The instrument displayed good internal reliability (Cronbach's alpha=0.92) and test-retest reliability (Pearson's r=0.86).CONCLUSIONS:The new instrument, SAHLSA-50, has good reliability and validity. It could be used in the clinical or community setting to screen for low health literacy among Spanish speakers.

In its recently adopted Global Strategy on Infant and Young Child Feeding, the World Health Assembly called for urgent action in addressing the barriers to optimal feeding practices. This paper examines mothers' concerns about milk insufficiency as a major contributor to suboptimal infant feeding decisions, using survey data from peri-urban areas of two Bolivian cities. Mothers in the lowland modernizing city of Santa Cruz were more likely than mothers in the highland traditional city of Cochabamba to express concern about insufficient milk, and also less likely to feed their infants according to international recommendations. Furthermore, perceived milk insufficiency was particularly common among mothers of infants younger than 6 months of age -- an age at which infants are particularly vulnerable to the adverse effects of breast-feeding cessation and complementary feeding initiation. The paper concludes with policy, programme and research recommendations to address the critical problem of perceived insufficient breast milk.

New Latina immigrants face numerous linguistic, cultural, logistical, and material barriers to cervical cancer screenings. Promotoras (lay health advisors) are a proven strategy to promote utilization of care. Since the mid-1990s, interventions in North Carolina have aimed to connect Latina immigrants to a broader range of bridge persons. This study assessed the effect of bridge persons on utilization of cervical cancer screening by Latina immigrants in North Carolina. Women were recruited in Spanish-language churches in four counties ( N = 223). Logistic regression results show that persons known through advocacy organizations appeared to increase probability of recent Pap screening by an average of 10.4 percentage points ( p < 0.05). Promotoras remain more effective, increasing probability of screening by 12.9 percentage points ( p < 0.05) but few women (14%) knew one. No association was found with other bridge person profiles. Interventions are needed to better engage all bridge persons in linking immigrants to preventive health services.

Imparting the requirements of healthcare workforce legislation to students is only one aspect of preparing undergraduate healthcare management students to be effective managers. On first review, the Americans with Disabilities Act (ADA) appears quite straightforward. The Act applies to any employer with 15 or more employees and covers a full range of employment practices. What the law does not address are the skills in empathy and decision-making that are needed for effective implementation of the law. In this article, the authors describe an experiential learning model that was designed to teach healthcare management majors, (soon-to-be healthcare managers), not only the provisions of the ADA law but also skills in empathy and critical decision-making. Reflections from student participants are included. These reflections are examples of changes in students' empathy occurring as a result of participation in the ADA Experience. The authors also present actual case requests for "reasonable accommodation" made by persons employed in a healthcare setting.

The U.S. is experiencing its highest immigration rate since the 1930s. The largest proportion of immigrants comes from Latin America, and women constitute a large and growing fraction of this group. Although our knowledge of the relationship between migration and women's health is increasing, research in this area is still needed, particularly in areas experiencing rapid changes in their Latino populations. Yet research is impeded by the absence of an adequate sampling frame: Latina immigrants remain a largely hidden population. This study tests in four North Carolina counties a church-based sampling frame for Latina immigrant women in their reproductive years. In the study area, on an average week, 20% of the Spanish-speaking population attends church (two-thirds are Catholic). Compared against Census data for the study area, the study sample (n = 706) provided a comparable representation of different national origins. New entrants to the U.S. and married women were overrepresented in the church-based sample. The young (under age 30), and women at the lowest and highest extremes of educational attainment were underrepresented in churches. While a church-based sample is not entirely comparable to the Census, churches can provide timely and cost-effective access to a rapidly changing population of new immigrants. Church-based research should be complemented with research in other settings, adjusting sampling weights for overlap between sampling frames.

In Brief This commentary discusses the need to train health professionals in “health Spanish” and related culture learning to provide quality health care to this immigrant population.

The number of Latinos in North Carolina grew by almost 400% between 1990 and 2000. The rapid change in demographics in this state and other southeastern states has caught healthcare providers unprepared. Lack of ability to communicate with Latino patients may result in errors in diagnosis or reduced compliance with recommended treatments. The Culturally and Linguistically Appropriate Services (CLAS) Standards, published in 2001, mandate culturally and linguistically appropriate services for persons with limited English proficiency. This paper describes an innovative strategy to promote Spanish and culture-learning skills of healthcare providers and presents results of the evaluation conducted to determine its impact on access to quality care. The evaluation used a 360° case study design, at 1-year follow-up. Use of Spanish language health-related materials is key to the training's success. The authors make recommendations for replication of the integrated language and culture-training model in other new settlement areas, especially those in the southeast of the United States.

Piwoz and colleagues describe the lessons learned from breastfeeding promotion in relation to the need for improvement in complementary infant-feeding practices worldwide. They note that a major obstacle is the complexity of complementary feeding; not only are the messages regarding optimal complementary feeding difficult to articulate but measurement of these feeding behaviors is also problematic. The authors point out that indicators of breastfeeding developed by the World Health Organization (WHO) have served to focus attention on optimal breastfeeding for both education and assessment purposes. They then describe several aspects of complementary feeding (dietary diversity diet quality and feeding frequency) that should be included in any comprehensive set of infant-feeding indicators. (excerpt)

In the US, prenatal care is positively associated with improved birth outcomes. However, among Mexican-born Latinos, rates of low birth weight are lower than those of US-born counterparts despite the fact that recently arrived Latino immigrants are less likely to have received adequate prenatal care. The “birth weight paradox,” identified through analysis of the HHANES, appears to hold constant across variations in age, marital status or educational attainment. The authors explore Latina immigrant's perceptions of resilience factors related to these better birth outcomes through focused group interviews, photonarratives, and documentation of local kin networks. The women's responses are grouped into five resilience factors and one risk complex that have the potential to further explain the HHANES findings. Women's responses, the stories of their photographs, and kin networks are presented. Knowledge of these protective and risk factors can be useful to health professionals and Latino advocacy groups in the design of community-based interventions that protect health status and promote the practice of protective health behaviors within immigrant families and communities.

Exclusive and extended breast feeding is responsible for much of the fertility limitation and child spacing throughout the world. In many developing countries, where breast feeding is almost universal and of long duration, postpartum amenorrhea protects women from closely spaced subsequent pregnancies. However, at the same time, increased pressures toward modernization, rapid rural-to-urban migration, frequent advertisements of powdered milk substitutes, and the increased employment of women outside of the home are adversely affecting traditional breast feeding practices. In Bolivia, almost all women breast feed their newborn infants, for periods up to 2 years. This paper reports findings which describe and compare patterns of women's differential knowledge of breast feeding and lactational amenorrhea resulting from data collection using a survey instrument and a focus group guide. The findings are part of a larger study on infant feeding and child spacing conducted in periurban communities in Bolivia. Current and historical trends with regard to paradigm and methodology in social science research are reviewed and the survey/focus group research method is described.

Maternal mortality is a problem of considerable magnitude yet it still receives inadequate attention in developing countries. Recently, increased attention has been given to preventing maternal mortality through innovative programmes of service delivery, in which success is usually measured by outcomes such as changes in the ratio of maternal mortality/morbidity or an increase in use of health services, without looking at the actual process of service delivery. This paper presents a model of participative management as a means of changing the process of maternal health care delivery. It was developed as part of Proyecto MADRE, a community-based reproductive health project in Cochabamba, Bolivia.