7: No. 2, March 2010
Cardiovascular Health in Underserved Communities
Lucinda L. Bryant, PhD, MSHA; Nancy P. Chin, PhD, MPH; Lesley A. Cottrell, PhD; Joyce M. Duckles, MA; I. Diana Fernandez, MD, MPH, PhD; D. Marcela Garces, MD, MSPH; Thomas C. Keyserling, MD, MPH; Colleen R. McMilin, MPH; Karen E. Peters, DrPH; Carmen D. Samuel-Hodge, PhD, MS, RD; Shin-Ping Tu, MD, MPH; Maihan B. Vu, DrPH, MPH; Annette L. Fitzpatrick, PhD
Suggested citation for this article: Bryant LL, Chin NP, Cottrell LA, Duckles JM, Fernandez ID, Garces DM, et al. Perceptions of
cardiovascular health in underserved communities. Prev Chronic Dis 2010;7(2):A30.
mar/09_0004.htm. Accessed [date].
Cardiovascular disease is the leading cause of deaths and illnesses in US
adults, and the prevalence is disproportionately high in underserved
populations. In this study, we assessed respondents’ understanding of context-specific differences in knowledge and perceptions of disease, risk, and prevention in 6 underserved communities, with
the longer-term goal of developing appropriate
Thirty-nine small-group sessions and 14 interviews yielded data from 318 adults. Each site’s researchers coded, analyzed, and extracted key themes from local data. Investigators from all sites synthesized results
and identified common themes and differences.
Themes clustered in 3 areas (barriers to cardiovascular health, constraints related to multiple roles, and suggestions for effective communications and programs). Barriers spanned individual, social and cultural, and environmental levels;
women in particular cited multiple roles (eg, competing demands, lack of self-care). Programmatic
suggestions included the following: personal, interactive, social context; information in language that people use; activities built around cultural values and interests; and community orientation. In addition, respondents preferred health-related information from trusted groups (eg, AARP), health care providers (but with noticeable differences of opinion), family and friends, and printed materials.
Interventions to decrease barriers
to cardiovascular health are needed; these strategies should include family and community context, small groups, interactive methods, culturally sensitive materials, and trusted information sources. New-immigrant communities need culturally and linguistically tailored education before receiving more substantive interventions.
Back to top
Coronary heart disease (CHD) and stroke are the leading causes of deaths and illnesses
in US adults (1,2). More than 80 million American adults live with cardiovascular disease (CVD) (3). Disparities in prevalence in underserved populations are well documented (4-7). For this study, we understand “underserved” to mean social marginalization through the following mechanisms: low-income households and resource-poor communities, racial/ethnic minority status,
resource-poor rural areas, limited English proficiency, or recent migration to the United States.
Various ethnic and socioeconomic groups differ in individual health beliefs and practices (8).
Knowledge, personal experience, and broader social and cultural influences contribute to perceptions and health beliefs (9). A socioecological perspective (10-13)
recognizes that “most public health challenges (eg, encouraging people to exercise regularly, improve their
diet, refrain from smoking) are too complex to be understood adequately from single levels of analysis and require more comprehensive approaches that integrate psychological, organizational, cultural, community planning, and regulatory perspectives” (11).
The Prevention Research Centers Cardiovascular Health Intervention Research and Translation Network (PRC CHIRTN)
conducted this study to increase understanding of differences in knowledge and perceptions of CVD, risk, and prevention in underserved and understudied populations, with
the longer-term goal of addressing the disparities through community-specific interventions and communications. PRC CHIRTN is a collaboration among 6 universities and their partner communities — University of
Colorado Denver (UCD), University of Illinois at Chicago (UIC), University of North Carolina at Chapel Hill (UNC), University of Rochester School of Medicine and Dentistry (UR; lead center), University of Washington (UW), and West Virginia University (WVU). Details on its history, mission, and structure
are available elsewhere (14). The diversity of the network’s partner communities
provided a unique opportunity to conduct community-based participatory research to assess barriers to and facilitators of cardiovascular
health across populations. In this study, we address issues related to cultural and environmental differences in the knowledge base and perceptions of CVD,
risk factors, and prevention, including 1) barriers to and facilitators of
promotion, 2) desired sources of information, and 3) potentially successful avenues
for dissemination of information and interventions to reduce the burden of CVD
in underserved populations.
Back to top
Investigators from all of the 6 PRC CHIRTN sites shared leadership for the
project, first to select the research topic and then to reach consensus on a core protocol. Local community teams
or advisory committees participated to ensure relevance to partner communities and to assess
the language and clarity of discussion questions and research materials for
Institutional review boards at each university reviewed and approved the protocols for that site.
Investigators met monthly by telephone conference and in March 2008 in person at a national PRC CHIRTN
meeting to develop the core protocol and then to track progress and resolve questions.
The protocol included a series of discussion questions for use at all sites and suggested demographic items to document the diversity of samples and allow comparisons between sites.
A full list of questions and prompts is available from the corresponding author. Four categories framed the discussion questions:
- knowledge and perceptions of heart disease and stroke
- knowledge and perceptions of prevention
- sources and usefulness of health information
- dissemination methods and strategies
The suggested set of demographic information included age, sex, race/ethnicity, education, geographic location (rural
or urban), and length of residence in the United States (if an immigrant population). Several sites also collected information about participants’ knowledge of their cardiovascular risk status or history.
Each site chose the appropriate qualitative method for its partner community and site-specific goals, which in some cases
extended beyond this study’s aims. Five sites (UCD, UIC, UNC, UW, and WVU) conducted
small-group sessions of ethnically, geographically, or socioeconomically underserved
groups, and 1 (UR) conducted in-depth interviews and neighborhood walking tours
with families of urban school children. The facilitators or interviewers for all research sessions
were experienced university-based researchers trained in qualitative methods. Following principles of community-based participatory research that promote collaborative partnerships in all phases of research (15), community advisory groups identified and recruited participants representative of each community of interest.
On the basis of criteria reviewed and approved by local institutional review
participants provided oral or written consent.
Small-group sessions were conducted in English with 2 exceptions;
new-immigrant Hispanic sessions were conducted in Spanish (UIC), and Asian
immigrant groups were conducted in separate sessions in Mandarin, Cantonese,
Vietnamese, or Korean (UW). Small-group sessions took place during the summer of 2007. All sessions were audio-recorded; researchers at each site transcribed (and if necessary translated into English) that site’s recordings, removing any
personal identifiers. Site-specific details about the groups are provided (Table).
Investigators from all sites assembled a “universal” codebook. The codebook
consisted of a priori codes derived from the discussion questions and additional concepts that emerged during analysis.
The major coding categories were the following:
- individual factors
- prevention/factors and types
- prevention/being at risk
- disease/symptoms knowledge and understanding
- disease/disease outcome knowledge and understanding
- disease/risk knowledge and understanding
Personnel at each site open coded (16) that site’s transcripts; at least
2 researchers independently coded and then reconciled differences, using Atlas.ti (Atlas.ti
Scientific Software Development, GmbH, Berlin,
Germany) software at 4 sites and NVivo/NUD*IST (QSR International,
Cambridge, Massachusetts) at
2 sites to facilitate analysis. Investigators then conducted axial coding, combining the original codes into categories by connecting them “in terms of conditions that give rise to them, properties
that are common to them, strategies that guide them, and consequences they share” (16). After each site’s investigators
coded and identified themes, representatives from all sites met face-to-face and then by conference call to identify cross-cutting themes and differences across sites.
Investigators then selected representative quotations from their sites to illustrate the research findings.
Back to top
A total of 380 community members participated in qualitative projects across the
6 sites. Participants included 62 children (UR, WVU) with their parents and other interested adults. This analysis includes only the 318 adults
(Table). Of the adults, 85% were
women (some sites by design sampled only women); 22% were younger than 45 years, 32% were
aged 45-64, and 29% were aged 65 or older (additionally, 9% reported age as 35
or older, 1% reported age as 40 or older, and 6% did not provide age
information). Slightly more than half (54%) of
the adult participants were married.
Recruitment achieved the desired oversampling of at-risk populations. Most of the participants (89%) were of Hispanic ethnicity or nonwhite race; 39% reported themselves as African American, 25% Hispanic,
and 24% Asian.
More than one-fourth (27%)
of respondents had less than a high school education. Although only 2 sites collected information on insurance coverage (UCD, UIC), the rate of those with no insurance (43%) was
almost twice the national average (23%) (17). Three sites collected information on health history; 48% of participants self-reported a family history of heart disease (UCD,
UIC, UNC), and 28% self-reported a diagnosis of diabetes (UCD, UNC). Rural
residents made up 33% of the sample. All small-group sessions at WVU and UCD
took place in rural areas (small towns outside of Morgantown, West Virginia,
and small towns in the rural San Luis Valley of Colorado), and 51% of UNC
respondents identified themselves as rural residents.
Knowledge of disease, risk factors, disease outcomes, and prevention
Across varied sites and diverse populations, we found that participants who were not recent immigrants had basic general knowledge about CVD, risk factors, disease outcomes, and prevention but experienced locally specific challenges to putting knowledge into practice. Most participants generally recognized high blood pressure and high blood cholesterol
levels as risk factors for heart disease, understood the roles of lifestyle and genetics in these risk factors, knew the numbers that indicate high
blood pressure and high blood cholesterol levels, and recognized lifestyle and medications as components of reducing risk.
New immigrant populations (UW, UIC) had only rudimentary or incomplete knowledge about CVD, compared
with the more established populations. For example, most participants in the UW
small-group sessions knew high
levels of blood pressure were bad but had difficulties describing what high
blood pressure is. Participants in the UIC groups knew that CVD was related to lifestyle factors including diet but did not know the numbers defining high blood pressure and high blood cholesterol
Participants in these settings did not understand the importance of taking medication to treat high blood pressure and cholesterol levels.
Participants at all sites had less knowledge about stroke than about heart disease, and they reported fear of stroke. They expressed concern about the loss of independence associated with stroke, the resultant economic implications for families, and the burden on
members who provide care.
Barriers to putting knowledge into practice
Across small-group sessions and interviews, common socioecological themes
emerged as barriers to translating knowledge into
healthy behaviors: multiple role demands, lack of economic resources, social and cultural issues that include lack of family and community support for healthy habits, and concerns about health care.
Appendix A provides examples in participants’ own words.
Particularly for women, their multiple roles as wage-earners, household managers, child care providers, providers of elder care,
and people responsible for dealing with health care demands for all family
members left them too exhausted to attend to their own health, without time to exercise, and too overextended to prepare nutritious meals at home as often as they liked or knew they should.
Many respondents lamented the high price of fresh fruits and vegetables, the cost of gas for transportation, and the cost of health insurance.
Living in resource-poor communities contributed to their difficulties.
Respondents at most sites remarked on the number of fast-food restaurants, citing them as often the only source of meals outside the home. They observed that corner stores with limited fresh foods were more accessible than well-stocked supermarkets. Their neighborhoods often lacked safe walking environments or facilities such as parks, gyms, and playgrounds. Additionally, at some sites, a strong street culture (eg, drugs, violence) competed
with families for the attention of their children and created barriers to
healthy behaviors in the young. Even for respondents with health insurance, difficult access (eg, lack of transportation) created barriers to appropriate health care. Hispanic respondents noted the lack of providers who speak Spanish, and new immigrants
had problems navigating the US health care system and integrating it with traditional beliefs and practices. Asian
respondents preferred to use their own community physicians and pharmacists for advice and to rely on their own traditional remedies and products because
they perceived that they had access to few other resources for information. Respondents spoke of weather
and transportation as barriers to healthy physical activity.
Facilitators of putting knowledge into practice
Community and social context in some cases facilitated healthy behavior
(Appendix B). Family and friends provided knowledge and services such as child care. Learning occurred best in a social context, with information in
language that people use and understand. Social support
— walking partners, family reinforcement, healthy behavior role models — improved the likelihood of adopting and maintaining healthy changes. On an individual level, several people spoke of the
importance and the difficulty of motivation.
Sources and usefulness of information
Respondents identified a number of information sources that included health
care providers, family and friends, printed materials, and other media (eg,
Internet, television, radio). Asian immigrants (UW) trust health information
from physicians despite communication problems. They also trust information from
other providers (eg, acupuncturists), family or friends, and community centers
when offered in their native languages. Recent immigrant Hispanic respondents (UIC) reported receiving little CVD information in any form. Nonimmigrant groups (UR,
UCD) preferred peer-to-peer discussion groups and family and friends for information and to
generate strategies for putting knowledge into practice. Respondents from all sites found currently
available print and other media materials of limited usefulness.
Respondents provided suggestions for disseminating health information into
their communities. They identified the following characteristics of successful strategies: responding to the influences of intrapersonal (motivation), interpersonal (social), community (cultural), and institutional contexts. They
cited interactive personal contact, use of preferred language (“just being able to present things in a way that people can understand and give them ideas,
don’t just say — ‘here, eat healthy’” [UR]), and tailoring to cultural values and priorities of the local community (eg, promoting community gardens). Respondents recommended family-friendly group sessions (“a little workshop or a little women’s retreat or something like . . . , if I experienced it and did some things I would be more likely to incorporate them in my life”
They preferred to hear from informed family and friends, especially those who
speak of their own experiences; trusted groups (eg, AARP); and health care providers, but not always (“I wouldn’t really listen to a doctor. I would listen to a friend that has been through it.”
[UNC]). Asian and Hispanic immigrants (UIC, UW) expressed the need for educational materials in their own languages and
for dissemination approaches sensitive to community and culture.
Back to top
The diversity of PRC CHIRTN communities and successful sampling made it possible to collect new insights into knowledge, perceptions, and preferred dissemination methods that will facilitate community-specific prevention activities.
The results from this study indicate that many people (but not new immigrants) have adequate knowledge of
heart disease and its risk factors, including information about healthy lifestyles, but are less well informed about stroke. Another study
found that underserved people with
known elevated risk of CVD (18) had limited risk-factor knowledge, although women, rural residents, and those with higher incomes had
more awareness and knowledge. The predominance of women in our study may account for some of the difference. New immigrants — Hispanic and Asian — have a more immediate need for basic information.
Even with adequate knowledge, members of underserved populations have
difficulty putting what they know into practice. In particular, they, especially women, identify barriers related to multiple family- and work-based responsibilities (8,19-23) and a need for strategies and programs to promote and facilitate self-care. As previously reported in underserved groups, other barriers include economic constraints (19,21,22), social and cultural concerns (24), and access
Participants offered valuable suggestions for culturally appropriate, community-specific approaches to promote
- Interactive, hands-on programs in small groups, including social support to bolster motivation to comply with prevention and treatment regimens.
- Information from informed peers who have personal experience to
relate. We know from the literature and experience in our communities that
lay health workers, who have an intimate understanding of their community’s sociocultural background, experiences, challenges, and strengths are in a unique position to provide peer support for community members (10,25,26).
- “Real-world” vocabulary in the preferred language. A need exists
particularly in low-literacy communities for accurate, credible, and current information (27) in clear, conversational language (28), but research to date finds only mixed results for interventions to overcome literacy barriers (29). One of the PRC CHIRTN sites (UW) has had success using photography to solicit information for messaging on
topics, especially among older Asian immigrants (30), and 2 sites (UW, UIC)
have developed audio novellas to increase levels of cardiovascular health information in new-immigrant Hispanic groups.
- Improved communication with and information from health care providers.
- Assistance with child care and transportation.
- More community resources for physical activity and healthy food.
These suggestions emphasize the need to engage the community and the consumer in assessing needs and developing materials and programs, as recommended by the National Expert Panel on Community Health Promotion (31).
Although most study participants in this study reported basic CVD knowledge, many lacked resources or motivation to apply it. Effective interventions will need to address daily competing priorities and barriers to improving healthy behaviors. Programs
that focus on problem solving (a cognitive strategy) (32,33) or motivational
interviewing (a behavioral strategy) (34) offer promise. As an example,
responding to women in this study, 3 PRC CHIRTN sites (UCD, UNC, WVU) conducted
a second round of small-group sessions to tailor a problem-solving intervention to the community context, with the goal of improving participants’ capacity to manage their situations.
Limitations and strengths
Small-group sessions and interviews may not adequately mirror the characteristics of the community or population that they represent. The diversity of settings we reached suggests that the results described here reflect similarities and differences across underserved groups with increased CVD risk. Although the research sites used different data collection methods, the development of common protocols,
discussion questions, and coding schemes means that we spoke of the same issues in the same ways. Investigators from all sites
collaborated to conduct the highest level of analysis and synthesis, which increased the rigor of the results and the implications drawn from them.
Public health practitioners and programs must reach people at high risk and
engage them in prevention activities. The results of this study make it clear
that we need to move beyond individual- and knowledge-based interventions to new
approaches that involve social marketing; environmental change to improve access to
nutritious food, physical activity, and health care; and strategies tailored to the context.
This study identified a number of common barriers to cardiovascular health across groups of underserved populations that community interventions may address.
Although sensitivity to unique cultural settings must be considered, many similarities
exist across groups concerning suggestions for approaches to improve knowledge and CVD prevention practice. The socioecological perspective provides a framework for creating multifaceted disease prevention interventions and related
communication strategies that simultaneously target the different levels of influence and build on community strengths.
Back to top
The research reported in this publication was supported by the Centers for Disease Control and Prevention’s (CDC) Prevention Research Centers Program (PRC) Special Interest Project (SIP 9-05),
the Cardiovascular Health Intervention Research and Translation Network (PRC CHIRTN), through Cooperative Agreements U48-DP-000031
(University of Rochester, Thomas A. Pearson, principal investigator [PI]), U48-DP-000054
(University of Colorado, Lucinda L. Bryant,
PI), U48-DP-000048 (University of Illinois Chicago, Karen E. Peters, PI), U48-DP-000059
(University of North Carolina at Chapel Hill, Thomas C. Keyserling, PI), U48-DP-000050
(University of Washington, Annette L. Fitzpatrick, PI), and U48-DP-000052 (West Virginia University, William A. Neal, PI). The PRC CHIRTN is supported by CDC’s Division of Heart Disease and Stroke Prevention. We acknowledge the efforts of our community partners (advisory boards and teams), PRC CHIRTN colleagues, and the community member participants in the research.
Back to top
Corresponding Author: Lucinda L. Bryant, PhD, MSHA, Colorado School of
Public Health, University of Colorado Denver, 13001 East 17th Ave B-119,
Denver, CO 80045. Telephone: 303-724-4384. E-mail:
Author Affiliations: Nancy P. Chin, I. Diana Fernandez, University of
Rochester School of Medicine and Dentistry, Rochester, New York; Lesley A. Cottrell, West
Virginia University, Morgantown, West Virginia; Joyce M. Duckles, University of Rochester,
Rochester, New York; D. Marcela Garces,
University of Illinois at Rockford, Rockford, Illinois; Thomas C. Keyserling, Carmen D. Samuel-Hodge, Maihan B. Vu, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina; Colleen R. McMilin, University of Colorado Denver,
Denver, Colorado; Karen E. Peters, University of Illinois at
Rockford, Rockford, Illinois, and University of Illinois at Chicago, Chicago,
Illinois; Shin-Ping Tu, Annette L. Fitzpatrick, University of
Washington, Seattle, Washington.
Back to top
- Health United States 2006. National Center for Health Statistics; 2006.
Accessed July 31, 2008.
- Addressing the nation’s
leading killers, 2006. Atlanta (GA): Centers for Disease Control and
- Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al.
Heart disease and stroke statistics: 2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117(4):e25-e146.
- Kurian AK, Cardarrelli KM.
Racial and ethnic differences in cardiovascular disease risk factors: a systematic review. Ethn Dis 2007;17(1):143-52.
- Kanjilal S, Gregg EW, Cheng YJ, Zhang P, Neldon DE, Mensah G, et al.
Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971-2002. Arch Intern Med 2006;166(21):2348-55.
- Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JB.
State of disparities in cardiovascular health in the United States. Circulation 2005;111(10):1233-41.
- Colleran KM, Richards A, Shafer K.
Disparities in cardiovascular disease risk and treatment: demographic comparison. J Investig Med 2007;55(8):415-22.
- Samuel-Hodge CD, Headen SW, Skelly AH, Ingram AF, Keyserling TC, Jackson EJ,
Influences on day-to-day management of type 2 diabetes among African-American women:
spirituality, the multi-caregiver role, and other social context factors. Diabetes Care 2000;23(7):928-33.
- Cristancho S, Garces DM, Peters K, Mueller B.
Listening to rural Hispanic communities in the Midwest:
a community-based participatory assessment of major barriers to health care access and use. Qualitative Health Research 2008;18(5):633-46.
- DeBate R, Plescia M, Joyner D, Spann L.
A qualitative assessment of Charlotte REACH:
an ecological perspective for decreasing CVD and diabetes among African Americans. Ethn Dis 2004;14(3
- Stokols D.
Translating social ecological theory into guidelines for community health promotion.
Am J Health Promot 1996;10(4):282-98.
- Sallis JF, Owen N. Ecological models of health behavior. In: Glanz K, Rimer BK, Lewis FM, editors. Health
behavior and health education: theory, research, and practice. San Francisco
(CA): Jossey-Bass, 2004.
- Weisner TS. Introduction. In: Weisner TS, editor. Discovering successful pathways in
children’s development: mixed methods in the study of childhood and family
life. Chicago (IL): The University of Chicago Press; 2005.
- Farris RP, Pearson T, Fogg T, Bryant L, Peters K, Keyserling T, et al.
Building capacity for heart disease and stroke prevention research:
the Cardiovascular Health Intervention Research and Translation Network. Health Promot Pract 2008;9(3):220-7.
- Israel BA, Schulz AJ, Parker EA, Becker AB.
Review of community-based research:
assessing partnership approaches to improve public health. Ann Rev Public Health 1998;19:173-202.
- Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and
techniques. Newbury Park (CA): Sage Publications; 1990.
- Cohen RA, Martinez ME. Health insurance coverage: early release of estimates from the National Health Interview Survey, January – June 2007. December 2007.
Accessed November 23, 2008.
- Homko CJ, Santamore WP, Zamora L, Shirk G, Gaughan J, Cross R, et al.
Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease.
J Cardiovasc Nurs 2008;23(4):332-37.
- Brett JA, Heimendinger J, Boender C, Morin C.
Using ethnography to improve intervention design. Am J Health Promot 2002;16(6):331-40.
- Gatewood JG, Litchfield RE, Ryan SJ, Myers JD, Geadelmann JD, Pendergast JF,
Perceived barriers to community-based health promotion program participation. Am J Health Behav 2008;32(3):260-71.
- Punzalan C, Paxton KC, Guentzel H, Bluthenthal RN, Staunton AD, Mejia G,
Seeking community input to improve implementation of a lifestyle modification program. Ethn
Dis 2006;16(Suppl 1):S79-88.
- Speck BJ, Hines-Martin V, Stetson BA, Looney SW.
intervention aimed at increasing physical activity levels in low-income
women. J Cardiovasc Nurs 2007;22(4):263-71.
- Goldman RE, Parker DR, Eaton CB, Borkan JM, Grambling R, Cover RT, et al.
Patients’ perceptions of cholesterol, CVD risk, and risk communication strategies. Ann Fam Med 2006;4(3):205-12.
- Harralson TL, Cousler Emig J, Polansky M, Walker RE, Otero Cruz JO, Garcia-Leeds C.
Un corazon saludable:
factors influencing outcomes of an exercise program designed to impact cardiac and metabolic risks among urban Latinas. J Community Health 2007;32(6):401-12.
- Kim S, Koniak-Griffin D, Flaskerud JH, Guarnero PA.
The impact of lay
health advisors on cardiovascular health promotion using a community-based
participatory approach. J Cardiovasc Nurs 2004;19(3):192-9.
- Boutin-Foster C, George KS, Samuel T, Fraser-White M, Brown H.
Training community health workers to be advocates for health promotion:
efforts taken by a community-based organization to reduce health disparities in cardiovascular disease. J Community Health 2008;33(2):61-8.
- Institute of Medicine. Health literacy: a prescription to end confusion. Washington
(DC): National Academies Press; 2004.
- Merriman B, Ades T, Seffrin JR.
Health literacy in the information age: communicating cancer information to patients and families.
CA Cancer J Clin 2002;52(3):130-3.
- Pignone M, DeWalt DA, Sheridan S, Berkman N, Lohr KN.
Interventions to improve health outcomes for patients with low literacy: a
systematic review. J Gen Intern Med 2005;20(2):185-92.
- Fitzpatrick AL, Steinman LE, Tu S-P, Ly KA, Ton TGN, Yip M-P, et al.
Communicating with pictures:
perceptions of cardiovascular health in Asian immigrants. Am J Public Health 2009;99(12):2147-9.
- Navarro AM, Voetsch KP, Liburd LC, Giles HW, Collins JL. Charting the future of community health promotion: recommendations from the National Expert Panel on Community Health Promotion. Prev Chronic Dis 2007;4(3).
Accessed December 4, 2009.
- Hill-Briggs R, Gemmell L.
Problem solving in diabetes self-management and control: a systematic review of the literature. Diabetes Educ 2007;33(6):1032-50.
- D’Zurilla TJ, Nezu AM, Maydeu-Olivares A. Social problem-solving inventory-revised (SPSI-R)
manual. North Tonawand (NY): Multi-Health Systems; 2002.
- Rollnick S, Mason P, Butler C, editors. Health behavior change: a guide for
practitioners. London (UK): Churchill Livingstone; 1999.
Back to top