Comparative public health research makes wide use of self-report instruments. For example, research identifying and explaining health disparities across demographic strata may seek to understand the health effects of patient attitudes or private behaviors. Such personal attributes are difficult or impossible to observe directly and are often best measured by self-reports. Defensible use of self-reports in quantitative comparative research requires not only that the measured constructs have the same meaning across groups, but also that group comparisons of sample estimates (eg, means and variances) reflect true group differences and are not contaminated by group-specific attributes that are unrelated to the construct of interest. Evidence for these desirable properties of measurement instruments can be established within the confirmatory factor analysis (CFA) framework; a nested hierarchy of hypotheses is tested that addresses the cross-group invariance of the instrument's psychometric properties. By name, these hypotheses include configural, metric (or pattern), strong (or scalar), and strict factorial invariance. The CFA model and each of these hypotheses are described in nontechnical language. A worked example and technical appendices are included.

The purpose of this study was to examine the association between socioeconomic status (SES) and leukocyte telomere length (LTL) – a marker of cell aging that has been linked to stressful life circumstances – in a nationally representative, socioeconomically and ethnically diverse sample of US adults aged 20–84. Using data from the National Health and Nutrition Examination Survey (NHANES), 1999–2002, we found that respondents who completed less than a high school education had significantly shorter telomeres than those who graduated from college. Income was not associated with LTL. African-Americans had significantly longer telomeres than whites, but there were no significant racial/ethnic differences in the association between education and telomere length. Finally, we found that the association between education and LTL was partially mediated by smoking and body mass index but not by drinking or sedentary behavior.

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Objective. To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ ethnic groups that allows reliable, valid, and unbiased comparisons across these groups. Data Source/Data Collection. Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) (N 5 1,664). Study Design/Methods. In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups. Principal Findings. The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability. Conclusions. The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities.Key Words. Quality of care, race, ethnicity, measurement, measurement invariance, factorial invariance, physician-patient communication, physician-patient interaction Evidence of racial/ethnic disparities in quality of care is accumulating rapidly. Widespread disparities have been observed in many components of quality such as effectiveness of care for chronic and acute health conditions, patient safety, timeliness, communication, respectfulness, and discrimination r Health Research and Educational Trust

Background and objectives: Few studies have examined health literacy in patients with end stage kidney disease. We hypothesized that inadequate health literacy in a hemodialysis population is common and is associated with poorer access to kidney transplant wait-lists.Design, setting, participants, & measurements: We enrolled 62 Black and White maintenance hemodialysis patients aged 18 to 75. We measured health literacy using the short form Test of Functional Health Literacy in Adults. Our primary outcomes were (1) time from dialysis start date to referral date for kidney transplant evaluation and (2) time from referral date to date placed on kidney transplant wait-list. We used Cox proportional hazard models to examine the association between health literacy (adequate versus inadequate) and our outcomes after controlling for demographics and co-morbid conditions.Results Conclusions: Inadequate health literacy is common in our hemodialysis patient population and is associated with a lower hazard of referral for transplant evaluation. Strategies to reduce the impact of health literacy on the kidney transplant process should be explored.

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The effects of cultural factors on condom use were assessed in a random digit-dialing household survey of 1,600 unmarried Latino adults in 10 states with large Latino populations. Measures of traditional gender-role beliefs, sexual coercion, sexual comfort, and self-efficacy in using condoms were developed specifically for this population. A multisample structural equation model analysis included 594 men who reported one or more heterosexual partners in the 12 months before interview. As predicted, men with more traditional gender-role beliefs reported more sexual coercion and less sexual comfort. Men reporting more sexual coercion and less sexual comfort had lower condom self-efficacy. Men with more condom self-efficacy and stronger condom social norms reported more condom use.

Importance Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood. Objective Toanalyze the effect of a decision support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision-making among women of varying literacy and numeracy levels. Design Randomized trial conducted from 2010-2013. Setting Prenatal clinics at three county hospitals, a community clinic, an academic center, and three medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants English- or Spanish-speaking women who had not yet undergone screening and/or diagnostic testing and remained pregnant at 11 weeks gestation (n=710). Interventions A computerized, interactive decision support guide and access to prenatal testing with no out-of-pocket expense (n=357) or usual care as per current guidelines (n=353). Main Outcome Measures The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge, risk comprehension, decisional conflict and decision regret at 24-36 weeks' gestation. Results Women randomized to the intervention group, compared to those randomized to the control group, were less likely to have invasive testing [5.9% vs. 12.3%, odds ratio (OR) 0.45, 95% CI 0.25-0.80] and more likely to forego testing altogether [25.6% vs. 20.4%, OR 3.30 (reference group screening followed by invasive testing), CI 1.43-7.64]. They also had higher knowledge scores (9.4 vs. 8.6 on a 15-point scale, mean group difference 0.82, CI 0.34-1.31), and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs. 59.0%, OR 1.95, CI 1.39-2.75) and their age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs. 46.1%, OR 1.66, CI 1.22-2.28). Significant differences did not emerge in decisional conflict or decision regret. Conclusions and Relevance Full implementation of prenatal testing guidelines using a computerized, interactive decision support guide in the absence of financial barriers to testing resulted in lesser test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making, and fewer women undergoing testing.