Patient-Physician Language Concordance and Lifestyle Counseling Among Spanish-Speaking Patients

Objective Patient-physician language discordance is associated with worse quality of healthcare for patients with limited English proficiency. Patients with language-discordant physicians have more problems understanding medical situations. The impact of patient-physician language concordance on lifestyle counseling among Spanish-speaking patients is not known. Methods We performed a retrospective medical record review and identified 306 Spanish-speaking patients who used interpreter services between June 2001 and June 2006 in two Boston-based primary care practices. Our primary outcome was counseling on exercise, diet, and smoking. Our main predictor of interest was patient-physician language concordance. Results Patients with language-concordant physicians were more likely to be counseled on diet and physical activity compared to patients with language-discordant physicians. After adjustment for age, sex, insurance status, number of primary care visits, and comorbidity score, these differences in counseling persisted for diet [odds ratio (OR) = 2.2, CI 1.3–3.7] and physical activity (OR = 2.3, CI 1.4–3.8). There was no significant difference with regard to discussion of smoking (OR = 1.3, CI 0.8–2.1). Conclusions Spanish-speaking patients are more likely to discuss diet and exercise modification if they have a Spanish-speaking physician compared to those having a non-Spanish-speaking physician. Further research is needed to explore whether matching Spanish-speaking patients with Spanish-speaking providers may improve lifestyle counseling.     

Perceived Barriers to Nurse Practitioner Practice in Rural Settings

CONTEXT: Rural residents experience the same incidence of acute illness as urban populations and have higher levels of chronic illness. Overall, access to adequate rural health care is limited. Nurse practitioners (NPs) have been identified as safe, cost-effective providers in meeting these challenges in rural settings. PURPOSE: This replication study was conducted to examine NP perceptions of barriers to rural practice in Minnesota. Findings were compared to earlier studies to examine issues that have persisted over time. METHODS: A Barriers to Practice checklist was mailed to NPs from the database of the Board of Nursing of a midwestern state. Rural NPs (n = 191) identified and described barriers to practice and rated the overall restrictiveness of their practice. FINDINGS: Barriers to practice were perceived to be prevalent. Persisting barriers continued to stand in the way of full utilization of NP roles. Lack of understanding of NP roles on the part of the public and other health professionals has been particularly problematic over time. Key issues in 2001 were low salaries, lack of adequate office space, and a limited peer network. Perceived restrictiveness of the practice climate, gauged as somewhat restrictive, remained unchanged between 1996 and 2001. CONCLUSIONS: NPs have an excellent history of meeting rural primary health care needs. Enhancing the NP work environment could prove instrumental to retaining these professionals in the work force and thereby contribute to improved access and quality of care in underserved rural communities.     

Primary Care Practice Management in Rural and Urban Veterans Health Administration Settings

Limited access to specialty care in rural settings may result in more expectations of primary care providers and a higher demand for primary care. The authors used survey and administrative data from 1999 from the Veterans Health Administration (VHA) to compare primary care practice management and performance in 19 rural to 103 urban VHA hospitals nationally. Rural VHA hospitals were smaller, less likely to be academically affiliated, and had fewer integrated specialty care services. Primary care providers in rural settings were more likely to manage specialty care services, provide continuity across patient care settings, and have complete responsibility for a broader range of services. However, rural hospitals had more staff per patient allocated to primary care than did urban hospitals. Patients in rural settings received comparable quality care to those in urban settings, and they appeared to be more satisfied with the care they received. Within the VHA system, primary care providers in rural settings provided a broader range of services than those in urban ones. This increased breadth may be attributable to the lack of availability of integrated specialty care services in rural settings. Because of this broader range of responsibilities, the provision of primary care in rural settings may require higher staffing patterns and may be inherently more costly than in urban settings; therefore, researchers should be cautious when comparing primary care expenditures across rural and urban settings.     

Patient-Physician Language Concordance and Use of Preventive Care Services Among Limited English Proficient Latinos and Asians

ObjectivesPatient-physician language concordance among limited English proficient (LEP) patients is associated with better outcomes for specific clinical conditions. Whether or not language concordance contributes to use of specific preventive care services is unclear.MethodsWe pooled data from the 2007 and 2009 California Health Interview Surveys to examine mammography, colorectal cancer (CRC) screening, and influenza vaccination use among self-identified LEP Latino and Asian (i.e., Chinese, Korean, and Vietnamese) immigrants. We defined language concordance by respondents reporting that their physician spoke their non-English language. Analyses were completed in 2013–2014.ResultsLanguage concordance did not appear to facilitate mammography use among Latinas (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI] 0.72, 1.45). Among Asian women, we could not definitively exclude a negative association of language concordance with mammography (AOR=0.55, 95% CI 0.27, 1.09). Patient-physician language concordance was associated with lower odds of CRC screening among Asians but not Latinos (Asian AOR=0.50, 95% CI 0.29, 0.86; Latino AOR=0.85, 95% CI 0.56, 1.28). Influenza vaccination did not differ by physician language use among either Latinos or Asians.ConclusionsPatient-physician language concordance was not associated with higher use of mammography, CRC screening, or influenza vaccination. Language concordance was negatively associated with CRC screening among Asians for reasons that require further research. Future research should isolate the impact of language concordance on the use of preventive care services from health system factors.Language barriers in health care may reduce the quality of care received by limited English proficient (LEP) patients, serve as a hurdle to the receipt of preventive care services, and contribute to health disparities.^1–3 Patient-physician communication is enhanced by language concordance (i.e., when the physician is fluent in the patient''s non-English language). Language concordant care is associated with patient trust in physicians and greater satisfaction,^4,5 increased medication adherence,⁶ and higher rates of glycemic control among diabetic patients.⁷ In contrast, language barriers are not associated with other conditions, such as mortality or length of stay in patients with myocardial infarction.⁸Latinos and Asians are the fastest-growing racial/ethnic minority groups in the United States.⁹ Preventive care services use, such as mammography for breast cancer screening, colorectal cancer (CRC) screening, and influenza vaccination, are suboptimal in both populations.^10–16 Studies of the association between patient-physician language concordance and completion of preventive care practices report inconsistent findings. Prior work, while limited in scope, suggests that language concordance may be negatively associated with receipt of CRC screening and positively associated in some groups with mammography and influenza vaccination.^17–20 However, this work has been limited by sampling selection and by significant variation in key definitions such as LEP or language concordance itself.^18–20The California Health Interview Survey (CHIS) includes representative samples of major racial/ethnic minority groups and is conducted in multiple languages including English, Spanish, Mandarin, Cantonese, Korean, and Vietnamese. We used CHIS to examine the associations between patient report of patient-physician language concordance and patient report of use of mammography, CRC screening, and influenza vaccination among LEP Latino and Asian Americans in California.     

Comparison of Program Costs for Parent-Only and Family-Based Interventions for Pediatric Obesity in Medically Underserved Rural Settings

ABSTRACT:  Purpose: To compare the costs of parent-only and family-based group interventions for childhood obesity delivered through Cooperative Extension Services in rural communities. Methods: Ninety-three overweight or obese children (aged 8 to 14 years) and their parent(s) participated in this randomized controlled trial, which included a 4-month intervention and 6-month follow-up. Families were randomized to either a behavioral family-based intervention (n = 33), a behavioral parent-only intervention (n = 34), or a waitlist control condition (n = 26). Only program costs data for the parent-only and family-based programs are reported here (n = 67). Assessments were completed at baseline, post-treatment (month 4) and follow-up (month 10). The primary outcome measures were total program costs and cost per child for the parent-only and family interventions. Findings: Twenty-six families in the parent-only intervention and 24 families in the family intervention completed all 3 assessments. As reported previously, both intervention programs led to significantly greater decreases in weight status relative to the control condition at month 10 follow-up. There was no significant difference in weight status change between the parent-only and family interventions. Total program costs for the parent-only and family interventions were $13,546 and $20,928, respectively. Total cost per child for the parent-only and family interventions were $521 and $872, respectively. Conclusions: Parent-only interventions may be a cost-effective alternative treatment for pediatric obesity, especially for families in medically underserved settings.     

Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings

BackgroundA major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources.ObjectiveThis study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program.DesignWe conducted a 1-year prospective randomized controlled clinical trial.Participants/settingThe study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007.InterventionThe intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74).Main outcome measuresProgram delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample.Statistical analyses performedNonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance.ResultsMedian weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control).ConclusionsBoth the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.     

Provider,Patient, and Family Perspectives of Adolescent Alcohol Use and Treatment in Rural Settings

Purpose: We examined rural primary care providers’ (PCPs) self‐reported practices of screening, brief interventions, and referral to treatment (SBIRT) on adolescent alcohol use and examined PCPs’, adolescents’, and parents’ attitudes regarding SBIRT on adolescent alcohol use in rural clinic settings. Methods: In 2007, we mailed surveys that inquired about alcohol‐related knowledge, attitudes, and treatment practices of adolescent alcohol use to all PCPs in 8 counties in rural Pennsylvania who may have treated adolescents. We then conducted 7 focus groups of PCPs and their staffs (n = 3), adolescents (n = 2), and parents (n = 2) and analyzed the narratives using structured grounded theory, evaluating for consistent or discordant themes. Results: Twenty‐seven PCPs from 7 counties returned the survey. While 92% of PCPs felt that routine screening for alcohol use should begin by age 14, 84% reportedly screened for alcohol use occasionally, and reportedly 32% screened all adolescent patients. The provider focus groups (n = 20 PCPs/staff) related that SBIRT for alcohol use for adolescents was not currently effective. Poor provider training, lack of alcohol screening tools, and lack of referral treatment options were identified barriers. Adolescents (n = 12) worried that physicians would not maintain confidentiality. Parents (n = 12) acknowledged a parental contribution to adolescent alcohol use. All groups indicated computer‐based methods to screen for alcohol use among adolescents may facilitate PCP engagement. Conclusions: Despite awareness that rural adolescent alcohol use is a significant problem, PCPs, adolescents, and parents recognize that SBIRT for adolescent alcohol use in rural PCP settings is ineffective, but it may improve with computer‐based screening and intervention techniques.     

The Role of Women in Agriculture and Rural Settings

ABSTRACT: Women in rural Australia fill many roles, some of which are influenced by the mandate of tradition, the effects of isolation, or change in the economic and social environments. This paper presents a review of literature pertaining to the role of women in agriculture and rural settings. Three groups of women are considered - those on the land; women who live in small towns; and those who live in mining and construction camps. Discussion will reveal that women in rural Australia are not afforded the recognition they deserve and strive for. The traditional perception of the woman in rural Australia as a subservient, domestic being is eroded to be replaced by the notion of a versatile, capable person whose contribution to society is unrecognised as it is often 'out of sight out of mind'.     

The Effect of Changes in Health Beliefs Among African-American and Rural White Church Congregants Enrolled in an Obesity Intervention: A Qualitative Evaluation

Church interventions can reduce obesity disparities by empowering participants with knowledge and skills within an established community. The purpose of this study was to evaluate the Biomedical/Obesity Reduction Trial (BMORe) and investigate changes in health beliefs among obese adult participants. Ten pre-/post-intervention focus groups applying the Health Belief Model conducted in two African-American churches in Tennessee (n = 20) and South Carolina (n = 20), and one rural Appalachian church in Kentucky (n = 21). Two independent coders using NVivo analyzed transcribed audio data and notes. Participants’ health status of being overweight/obese and having comorbidities of diabetes and high blood pressure motivated enrollment in BMORe. Initially participants voiced low self-efficacy in cooking healthy and reading food labels. BMORe made participants feel “empowered” after 12 weeks compared to initially feeling “out of control” with their weight. Participants reported improvements in emotional health, quality of life, and fewer medications. During post-intervention focus groups, participants reported increased self-efficacy through family support, sharing healthy eating strategies, and having accountability partners. Solidarity and common understanding among BMORe participants led focus group attendees to comment how their peers motivated them to stay in the program for 12 weeks. Long-term barriers include keeping the weight off by maintaining habits of exercise and healthy eating. Implementation of pre-/post-intervention focus groups is an innovative approach to evaluate an obesity intervention and track how changes in health beliefs facilitated behavior change. This novel approach shows promise for behavioral interventions that rely on participant engagement for sustained effectiveness.     

Beliefs about Causes and Consequences of Obesity among Women in Two Mexican Cities

Personal beliefs might be barriers to the prevention and treatment of obesity. To assess the beliefs about causes and consequences of and possible solutions to obesity among 18-40 years old women in two Mexican cities and to analyze the association with demographic variables, we developed a questionnaire and assessed the women''s weight status. The questionnaire was applied at two outpatient healthcare centres and assessed the responses by the Likert scale. Results were analyzed by demographics, using the chi-square and Spearman correlations. One thousand one hundred adult women participated in the study. Mean age was 27.8 years, and mean BMI (kg/m²) was 27.05. The prevalence of overweight and obesity was 35% and 24% respectively. The most mentioned causes of obesity were eating oil and fat (4.1), fried foods (4.1), and eating too much (4.00). The most reported consequences were diseases (4.1), discrimination (3.9), and early death (3.7). The main solutions were physical activity (4.2), healthful eating (4.2), and personal motivation (4.1). Age of participants higher than 30 years, living with a partner, having more than 6 years of education, and having overweight and obesity were predictors of more knowledge about the causes, consequences, and solutions. These Mexican women from low SES had reasonably good knowledge about the causes and consequences of obesity. Although improving education might be beneficial to prevent obesity, changes in environmental contingencies are also necessary to prevent this epidemic.Key words: Beliefs, Causes, Consequences, Obesity, Treatment, Mexico     

Obesity Metaphors: How Beliefs about the Causes of Obesity Affect Support for Public Policy

Context: Relatively little is known about the factors shaping public attitudes toward obesity as a policy concern. This study examines whether individuals' beliefs about the causes of obesity affect their support for policies aimed at stemming obesity rates. This article identifies a unique role of metaphor-based beliefs, as distinct from conventional political attitudes, in explaining support for obesity policies.
Methods: This article used the Yale Rudd Center Public Opinion on Obesity Survey, a nationally representative web sample surveyed from the Knowledge Networks panel in 2006/07 (N = 1,009). The study examines how respondents' demographic and health characteristics, political attitudes, and agreement with seven obesity metaphors affect support for sixteen policies to reduce obesity rates.
Findings: Including obesity metaphors in regression models helps explain public support for policies to curb obesity beyond levels attributable solely to demographic, health, and political characteristics. The metaphors that people use to understand rising obesity rates are strong predictors of support for public policy, and their influence varies across different types of policy interventions.
Conclusions: Over the last five years, the United States has begun to grapple with the implications of dramatically escalating rates of obesity. Individuals use metaphors to better understand increasing rates of obesity, and obesity metaphors are independent and powerful predictors of support for public policies to curb obesity. Metaphorical reasoning also offers a potential framework for using strategic issue framing to shift support for obesity policies.