Latino Women Study

1. Latino Women Study Creating a Health Behavior Questionnaire Presentation prepared for: University of Texas at Austin Dr. Mario De La Rosa, Ph.D. Patria Rojas, M.P.H., M.S.W. Florida International University Miami, Florida NIDA Grant R24 14260-02

2. Purpose of Presentation • 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.

3. Description of Study • The Women’s Study Project and The Latino Drug Abuse Research Center Rationale for Study: Lack of research on the intergenerational transmission of drug use from Latina mothers to daughter Focus of Study: • Mother/daughter attachment and substance abuse • Target Population: Drug using and non- drug using Latino mother/daughter Dyads older than 18 years of age.

4. Primary Constructs • Substance Abuse Among Latino Women: • Onset, frequency and level of use • Mother-Daughter Relationship: Primarily attachment • Family Support:Tangible and belonging.

5. Other Important Constructs • Health Behaviors • Religiosity • Acculturation • Addiction Cognitive Orientation • Nutrition • Sexual Risk Behaviors

6. The study’s core variables were identified Literature search was conducted on all the constructs The literature review process included: Search engines (i.e., FIU Library Catalog , HAPI, Wiley Science Electronic and Copernic among others) Obtaining scales from organizations’ personnel and from the creators of the different scales Discussing scales with creators of the scales when possible Reviewing the references of obtained articles. Review of Literature Activities

7. Scales were evaluated by two Ph.D. level and two Master level research team members with extensive research experience in collecting data on the drug using behaviors of Latino populations Weekly meetings were held to discuss scale appropriateness based on the literature review If scale was selected, researchers examined terminology and changed it as needed to increase clarity and appropriateness to the study’s region (i.e., Spanish terms to define “high on drugs” such as enchufado and colgado). Procedure for Review of Existing Scales

8. Procedure for Review of Existing Scales • If scale was selected and had subscales that were not congruent with the study’s objectives, they were eliminated (i.e., the substance use frequency from the ASI was replaced by the Drug Use Frequency scale) • If scales were selected but needed more congruency with the study’s objectives, those sections were added (i.e., the health behavior section on nontraditional medicine such as Santeria, herbal medications, and farmacias de barrio[1] (Lamazares, 2002). [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. In some instances these pharmacies may sell a combination herbal, alternative medicines and beauty supplies.

9. Questionnaire Development Phase: the initial process • Questions were created in English and back-translated into Spanish • Question were reviewed by the research team and later tested in the focus groups • Community outreach workers provided feedback on language appropriateness and clarity • Existing Spanish scales were modified to fit the Spanish style most often used by Southern Florida Latino population.

10. 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 Criteria Utilize to Determine the Inclusion of Existing Scales in the Questionnaire

11. Major Reasons for Scale Rejections: • No validity information • Inappropriate for the target population • Did not measure the construct of interest appropriately.

12. Scales In The Questionnaire

13. Substance abuse scales Reviewed but Excluded • Chemical Dependency Assessment Profile • Drug Screening Inventory • Composite International Diagnostic Interview.

14. Rationale for Exclusion of Substance Abuse and Attachment Scales • Inappropriate for our Study’s Population • Reliability Concerns • Validity Concerns

15. Selected Substance abuse scales: The decision making process • Addiction Severity Index (Medical, Employment, Legal, Sections of the Drugs/Alcohol and the Family/Social Measure) • Drug Use Frequency • Onset Scale • Health Related Functioning Regarding Alcohol Use (HDL)

16. Attachment Scales Reviewed But Excluded • The Adult Attachment Interview • Items Used to Assess Intimacy

17. Selected Attachment Scale: The decision Making Process • Adapted and modified the Inventory of Parent and Peer Attachment (IPPA) to include the mother’s perspective.

18. Examples of scales included and in the pre-testing phase

19. The First Draft: Additional steps • Instrument was created simultaneously in English and Spanish • Project staff translated and back-translated the instrument • Introductions were made more extensive in order to provide explanation of technical terminologies (i.e., sexual behavior section) and increase clarity and validity of the data collected • The use of tu or usted (show of respect for some Latinos) will be used at the interviewer’s discretion on an individual basis, but guidelines were provided for assessing the need to use formal vs. informal address.

20. Development of the Questionnaire: The Pre-testing phase • Staff discussion on rationale for Pre-testing the questionnaire • Discussion of staff on best approach for testing: Focus Group vs. Individual Pre-testing • Discussion on whether to test the entire questionnaire’s draft or only sections that were judged to be problematic by the research team • Staff decision to do both: a focus group and individual Pre-testing of selected sections of the questionnaire draft.

21. Pre-Test Phase: Using Focus Groups • Conducted in Spanish at a community based organization by community workers and FIU researchers • Selected focus group participants from study’s target community • Provided ethnic food and payment as incentive • Recorded and documented focus groups’ feedback • Evaluated the use of appropriate vocabulary on added and developed items such as the health behavior scale.

22. Pre- test Phase with Individual 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.

23. Pre- test Phase with Individual participants: 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.

24. Pre- test Phase with Individual participants: Results • Confirmed appropriateness and validated adapted scales and measures • Added additional questions to the alternative health behavior section • Reviewed and made changes to technical vocabulary based on participants’ feedback • Reduced the length of the questionnaire from 98 to 92 pages.

25. Summary and Conclusion • Collaboration with the women from the target community • culturally knowledgeable team of researchers and consultation with established researchers in the field • Feedback from the study’s target population was critical for increasing the questionnaire’s sensitivity and validity. • Adaptations to maximize its appropriateness to the target population in Miami Dade County. • Individuals from the target population provided valuable feedback which was incorporated in the final version of the instrument.

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

27. 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.htm Stevens, 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. references