Latino Women StudyLatino Women StudyCreating a Health Creating a Health

Behavior QuestionnaireBehavior Questionnaire

Presentation prepared for:Presentation prepared for:

University of Texas at AustinUniversity of Texas at AustinDr. Mario De La Rosa, Ph.D.Dr. Mario De La Rosa, Ph.D.

Patria Rojas, M.P.H., M.S.W.Patria Rojas, M.P.H., M.S.W.

Florida International UniversityFlorida International University

Miami, FloridaMiami, Florida

NIDA Grant R24 14260-02NIDA Grant R24 14260-02

To describe the process in developing a questionnaire for a NIDA funded study that is investigating the intergenerational transmission of drug use between Latino mothers and daughters in Miami, Florida.

The presentation will divided into phases: the initial development of the questionnaire and the pre-testing and modification phase of the questionnaire

This questionnaire will be utilized to document the relationship that may exist between 160 Latino mothers and daughters’ dyads (N=320 women) attachment experiences and their drug using behaviors.

Purpose of PresentationPurpose of Presentation

Description of StudyDescription of Study

► The Women’s Study Project and The Latino The Women’s Study Project and The Latino Drug Abuse Research CenterDrug Abuse Research Center

Rationale for Study: Lack of research on the Rationale for Study: Lack of research on the intergenerational transmission of drug use intergenerational transmission of drug use from Latina mothers to daughterfrom Latina mothers to daughter

Focus of Study:Focus of Study:► Mother/daughter attachment and substance Mother/daughter attachment and substance

abuse abuse ► Target Population: Drug using and non- drug Target Population: Drug using and non- drug

using Latino mother/daughter Dyads older using Latino mother/daughter Dyads older than 18 years of age. than 18 years of age.

Primary ConstructsPrimary Constructs

Substance Abuse Among Latino Women:Onset, frequency and level of use

Mother-Daughter Relationship: Primarily attachment

Family Support:Tangible and belonging.

Other Important ConstructsOther Important Constructs

►Health BehaviorsHealth Behaviors►ReligiosityReligiosity►AcculturationAcculturation►Addiction Cognitive OrientationAddiction Cognitive Orientation►NutritionNutrition►Sexual Risk BehaviorsSexual Risk Behaviors

Review of Literature Review of Literature Activities Activities

The study’s core variables were identifiedThe study’s core variables were identified Literature search was conducted on all the Literature search was conducted on all the

constructsconstructs The literature review process included:The literature review process included:

Search engines (i.e., FIU Library Catalog , Search engines (i.e., FIU Library Catalog , HAPI, Wiley Science Electronic and Copernic HAPI, Wiley Science Electronic and Copernic among others)among others)

Obtaining scales from organizations’ Obtaining scales from organizations’ personnel and from the creators of the personnel and from the creators of the different scalesdifferent scales

Discussing scales with creators of the scales Discussing scales with creators of the scales when possible when possible

Reviewing the references of obtained Reviewing the references of obtained articles.articles.

Procedure for Review of Existing Procedure for Review of Existing ScalesScales

► Scales were evaluated by two Ph.D. level Scales were evaluated by two Ph.D. level and two Master level research team and two Master level research team members with extensive research members with extensive research experience in collecting data on the drug experience in collecting data on the drug using behaviors of Latino populationsusing behaviors of Latino populations

► Weekly meetings were held to discuss scale Weekly meetings were held to discuss scale appropriateness based on the literature appropriateness based on the literature reviewreview

► If scale was selected, researchers examined If scale was selected, researchers examined terminology and changed it as needed to terminology and changed it as needed to increase clarity and appropriateness to the increase clarity and appropriateness to the study’s region (i.e., Spanish terms to define study’s region (i.e., Spanish terms to define “high on drugs” such as “high on drugs” such as enchufadoenchufado and and colgadocolgado).).

Procedure for Review of Existing Procedure for Review of Existing ScalesScales

► If scale was selected and had subscales If scale was selected and had subscales that were not congruent with the study’s that were not congruent with the study’s objectives, they were eliminated (i.e., the objectives, they were eliminated (i.e., the substance use frequency from the ASI was substance use frequency from the ASI was replaced by the Drug Use Frequency scale)replaced by the Drug Use Frequency scale)

► If scales were selected but needed more If scales were selected but needed more congruency with the study’s objectives, congruency with the study’s objectives, those sections were added (i.e., the health those sections were added (i.e., the health behavior section on nontraditional medicine behavior section on nontraditional medicine such as Santeria, herbal medications, and such as Santeria, herbal medications, and farmacias de barriofarmacias de barrio[1][1] (Lamazares, 2002). (Lamazares, 2002).

[1][1] Independently owned pharmacies found mostly in Latin American neighborhoods that began due to the high price of medications where the pharmacist may recommend medications, first aid and advice. Independently owned pharmacies found mostly in Latin American neighborhoods that began due to the high price of medications where the pharmacist may recommend medications, first aid and advice. In some instances these pharmacies may sell a combination herbal, alternative medicines and beauty supplies.In some instances these pharmacies may sell a combination herbal, alternative medicines and beauty supplies.

Questionnaire Development Phase: Questionnaire Development Phase: the initial processthe initial process

► Questions were created in English and back-Questions were created in English and back-translated into Spanishtranslated into Spanish

► Question were reviewed by the research Question were reviewed by the research team and later tested in the focus groupsteam and later tested in the focus groups

► Community outreach workers provided Community outreach workers provided feedback on language appropriateness and feedback on language appropriateness and clarityclarity

► Existing Spanish scales were modified to fit Existing Spanish scales were modified to fit the Spanish style most often used by the Spanish style most often used by Southern Florida Latino population. Southern Florida Latino population.

Criteria Utilize to Determine the Criteria Utilize to Determine the Inclusion of Existing Scales in the Inclusion of Existing Scales in the

QuestionnaireQuestionnaire► Sample criteria for selection of

scales

► Excellent reliability and validity scores (i.e., α=.93 for parent attachment on a sample of 27 adults).

► Language appropriateness for Latino women

► Cultural sensitivity► Widely used in other

studies► Available in English and

Spanish (Preferred)► Utilized with minority

women (Preferred)► Utilized with Latino

women (Preferred).

► C: Results from the review of literature:

► Over 35 scales were reviewed

(i.e., 3 acculturation scales, 3 attachment scales, 7 substance abuse, 4 social support)

► 3 substance abuse scales were combined to measure use, frequency, and health consequences

Major Reasons for Scale Rejections:

►No validity information►Inappropriate for the target population

►Did not measure the construct of interest appropriately.

Scales In The QuestionnaireScales In The Questionnaire

Name of the scale Construct Measured

Inventory of Parent and Peer Attachment (IPPA)

Mother and daughter attachment

Interpersonal Support Evaluation List (ISEL)  Tangible and belonging support

The Santa Clara Strength of Religious Faith Questionnaire

Religious behaviors

Addiction Severity Index (ASI) Medical status, employment and support, legal status, family/social status, and psychiatric status among substance abusers.

Drug Use Frequency (DUF) Frequency of drug use

Health Daily Living Frequency of alcohol use

Health Assessment Health Status, wellness behavior, use of alternative medicine

Sexual Behavior Sexual risky behavior

Addiction Cognitive Orientation Believes about substance abuse

Marlowe - Crowne Social Desirability Scale Social desirability

Chronic Stressors Stress level at the community, work, and personal level

Cultural Identity Scales Level of acculturation

24 hour Dietary Recall Nutrition and eating patterns

Substance abuse scales Substance abuse scales Reviewed but ExcludedReviewed but Excluded

Chemical Dependency Assessment Chemical Dependency Assessment ProfileProfile

Drug Screening InventoryDrug Screening Inventory Composite International Diagnostic Composite International Diagnostic

Interview.Interview.

Rationale for Exclusion of Rationale for Exclusion of Substance Abuse and Attachment Substance Abuse and Attachment

ScalesScales► Inappropriate for our Study’s Inappropriate for our Study’s

PopulationPopulation

►Reliability ConcernsReliability Concerns

►Validity ConcernsValidity Concerns

Selected Substance abuse Selected Substance abuse scales: The decision making scales: The decision making

process process Addiction Severity Index (Addiction Severity Index (Medical, Employment, Legal, Sections Medical, Employment, Legal, Sections

of the Drugs/Alcohol and the Family/Social Measureof the Drugs/Alcohol and the Family/Social Measure)) Drug Use FrequencyDrug Use Frequency Onset ScaleOnset Scale Health Related Functioning Regarding Health Related Functioning Regarding

Alcohol Use (HDL)Alcohol Use (HDL)

Attachment Scales Reviewed Attachment Scales Reviewed But ExcludedBut Excluded

The Adult Attachment InterviewThe Adult Attachment Interview Items Used to Assess IntimacyItems Used to Assess Intimacy

Selected Attachment Scale: Selected Attachment Scale: The decision Making Process The decision Making Process

►Adapted and modified the Inventory of Adapted and modified the Inventory of Parent and Peer Attachment (IPPA) to Parent and Peer Attachment (IPPA) to include the mother’s perspective.include the mother’s perspective.

Scales chosen for Mother and daughter attachment

Rationale for choosing IPPA

Inventory of Parent and Peer Attachment (IPPA)

High reliability measures Previously used with minority population Able to be modified in order to obtain mother’s

perspective on attachment.

Scales chosen for substance abuse

Rationale for choosing drug abuse scales

Parts of the Addiction Severity Index (ASI)

Drug use frequency scale (DUF)

Health Daily Living (HDL)

Onset scale

Accuracy Need to cover onset, frequency, addiction related

behavior and partner’s drug use. Previously used with Hispanic adults

Examples of scales included and in the Examples of scales included and in the pre-testing phasepre-testing phase

The First Draft: Additional The First Draft: Additional steps steps

Instrument was created simultaneously in English Instrument was created simultaneously in English and Spanishand Spanish

Project staff translated and back-translated the Project staff translated and back-translated the instrumentinstrument

Introductions were made more extensive in order to Introductions were made more extensive in order to provide explanation of technical terminologies (i.e., provide explanation of technical terminologies (i.e., sexual behavior section) and increase clarity and sexual behavior section) and increase clarity and validity of the data collectedvalidity of the data collected

The use of The use of tutu or or ustedusted (show of respect for some (show of respect for some Latinos) will be used at the interviewer’s discretion Latinos) will be used at the interviewer’s discretion on an individual basis, but guidelines were provided on an individual basis, but guidelines were provided for assessing the need to use formal vs. informal for assessing the need to use formal vs. informal address. address.

Development of the Development of the Questionnaire: The Pre-testing Questionnaire: The Pre-testing

phasephase ► Staff discussion on rationale for Pre-testing Staff discussion on rationale for Pre-testing

the questionnaire the questionnaire ► Discussion of staff on best approach for Discussion of staff on best approach for

testing: Focus Group vs. Individual Pre-testingtesting: Focus Group vs. Individual Pre-testing► Discussion on whether to test the entire Discussion on whether to test the entire

questionnaire’s draft or only sections that questionnaire’s draft or only sections that were judged to be problematic by the were judged to be problematic by the research teamresearch team

► Staff decision to do both: a focus group and Staff decision to do both: a focus group and individual Pre-testing of selected sections of individual Pre-testing of selected sections of the questionnaire draft. the questionnaire draft.

Pre-Test Phase: Using Focus Pre-Test Phase: Using Focus GroupsGroups

► Conducted in Spanish at a community based Conducted in Spanish at a community based organization by community workers and FIU organization by community workers and FIU researchersresearchers

► Selected focus group participants from study’s Selected focus group participants from study’s target communitytarget community

► Provided ethnic food and payment as incentiveProvided ethnic food and payment as incentive► Recorded and documented focus groups’ Recorded and documented focus groups’

feedbackfeedback► Evaluated the use of appropriate vocabulary Evaluated the use of appropriate vocabulary

on added and developed items such as the on added and developed items such as the health behavior scale.health behavior scale.

Pre- test Phase with Pre- test Phase with Individual participantsIndividual participants

► Five dyads from the target population were interviewed

► Interviews were done by four Latino women from Cuban, Dominican, Peruvian, and Puerto Rican descent.

► Interviews were conducted following the study’s protocol

► Interviews were done in private places that provided confidentiality for the participants

► Interview was confirmed to require 2.5 -3 hours.

Pre- test Phase with Individual Pre- test Phase with Individual participants: Resultsparticipants: Results

► Inconsistencies with interviewers’ instructions were corrected

► Editorial changes were made based on participants and interviewers’ feedback

► Directions for study’s interviewers were added or clarified

► Changes to the participants’ screening questionnaire were done to include drug abuse

► Response cards were added to maximize clarity and face validity.

Pre- test Phase with Individual Pre- test Phase with Individual participants: Resultsparticipants: Results

►Confirmed appropriateness and validated Confirmed appropriateness and validated adapted scales and measuresadapted scales and measures

►Added additional questions to the Added additional questions to the alternative health behavior sectionalternative health behavior section

►Reviewed and made changes to technical Reviewed and made changes to technical vocabulary based on participants’ vocabulary based on participants’ feedbackfeedback

►Reduced the length of the questionnaire Reduced the length of the questionnaire from 98 to 92 pages.from 98 to 92 pages.

Summary and ConclusionSummary and Conclusion

► Collaboration with the women from the target Collaboration with the women from the target communitycommunity

► culturally knowledgeable team of researchers and culturally knowledgeable team of researchers and consultation with established researchers in the consultation with established researchers in the field field

► Feedback from the study’s target population was Feedback from the study’s target population was critical for increasing the questionnaire’s sensitivity critical for increasing the questionnaire’s sensitivity and validity. and validity.

► Adaptations to maximize its appropriateness to the Adaptations to maximize its appropriateness to the target population in Miami Dade County. target population in Miami Dade County.

► Individuals from the target population provided Individuals from the target population provided valuable feedback which was incorporated in the valuable feedback which was incorporated in the final version of the instrument.final version of the instrument.

Summary and ConclusionSummary and Conclusion

The focus groups were critical for creating The focus groups were critical for creating and determining the appropriateness of the and determining the appropriateness of the scales, the language used and the scales, the language used and the relevance of specific phenomena for the relevance of specific phenomena for the target population.target population.Pilot testing the questionnaire during Pilot testing the questionnaire during interviews helped determine its lengthinterviews helped determine its length Knowledge of this process will be helpful Knowledge of this process will be helpful in the future construction of protocols to in the future construction of protocols to study Latino women.study Latino women.

Gil, R.M. & Vasquez, C.I. (1996). The Maria Paradox.  New York: Berkley Publishing.

Lamazares, S. (2002, December 17). Cada cuatro días y medio cierra una farmacia de barrio en la capital. Retrieved October 26, 2004, from http://www.boletinfarmacos.org/042003/noticias_de_americalatina.htmStevens, E.D. (1973).  Marianismo: The other face of machismo in Latin

America. In A. Decastello (Ed.), Female and Male in Latin America.  Pittsburgh: University of Pittsburgh Press.

Acknowledgements: The Latino Drug Abuse Research Center Women’s Study is funded by the National Institute of Drug Addiction (NIDA) Grant (grant #DA014260).We wish to thank Dr. Maria Felix Ortiz for her suggestions and useful feedback during the preparation of the study’s protocol and this presentation. Thanks to Michelle Hamann and Guitelle Rahil for their assistance.

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