F. Background, References, and Resources
On this Page
- F.1 Background to the Development of the H/L ATS
- F.2 References and Resources
- F.3 Contacts
This guide is intended to be used by health practitioners, researchers, and statisticians who are interested in collecting data on tobacco use, cessation, secondhand smoke, risk perceptions and social influences, and demographic information from Hispanic/Latino populations. Specific sections of the guide may be most appropriate for specific uses: health practitioners might use Sections A, B, and F; interviewer training may benefit most from Section B; and researchers and statisticians may want to consult Sections C, D, and E. In this section we provide this array of users with the detailed history, theoretical demands, and practical considerations informing the Hispanic/Latino Adult Tobacco Survey (H/L ATS). We conclude with a bibliographic list of resources subdivided by content area of the guide. Contact information completes the resources offered here.
F.1 Background to the Development of the H/L ATS
The H/L ATS is a culturally appropriate adult tobacco use questionnaire administered to determine among Hispanic and Latino adults in the United States the prevalence of tobacco use, exposure to secondhand smoke, and exposure to influences for and against tobacco use. The availability of a consistent, well-developed questionnaire will improve the quality of this information, which will in turn aid in the development of culturally sensitive and effective tobacco control programs for Hispanic and Latino populations. Section F.1 provides the user of this guide with the background and rationale for the development of these survey materials.
F.1.1 Purpose of a Culturally Appropriate H/L ATS
Hispanic and Latino persons residing in the United States embody a unique set of attitudes, behaviors, knowledge, experience, and other cultural characteristics. These characteristics call for a customized approach to measuring health-compromising behaviors such as tobacco use, in order that truly effective cessation and prevention programs may be developed in this population at the local, state, and regional levels (Kerner, Breen, Tefft, & Silsby, 1998). To this end, in 2002, under the direction of the Centers for Disease Control and Prevention (CDC), Office on Smoking and Health (OSH), the General Population State ATS was adapted to create the H/L ATS. The H/L ATS was designed specifically to measure general health, tobacco use, cessation, exposure to secondhand smoke, risk perceptions, social influences, and demographics among Hispanic and Latino adults.
For information and background on the General Population State ATS, see the Guidelines for Conducting General Population State Adult Tobacco Surveys (Mariolis, in press).
Growth in Hispanic and Latino Populations
The need for targeted, culturally sensitive tobacco use prevention programs is substantiated by the growing number of Hispanic and Latino persons residing in the United States. The U.S. Hispanic and Latino population already constitutes a large portion of the overall population, and the numbers are increasing rapidly. According to the U.S. Census Bureau, in 2003 there were 39.9 million Hispanic/Latino persons living in the United States (U.S. Census Bureau, 2004), a 78% increase over 1990 (22.4 million). It is expected that the number of Hispanic/Latino persons living in the United States will increase to 102.6 million by the year 2050. If these Census projections are correct, 24.4%, or about 1 of every 4 persons residing in the United States, will be of Hispanic or Latino origin (U.S. Census Bureau, 2004).
If the Hispanic/Latino adult smoking prevalence remains at its average level of 18.3% (1990–1999) for the next 50 years, the number of Hispanic and Latino adult smokers will increase from 3.8 million in the year 2000 to 11.0 million in the year 2050. Although the H/L ATS is not administered to those under the age of 18, data on adults will inform prevention programs for younger Hispanic and Latino persons, who are the largest minority youth population in the United States and 16% of the population under age 18 (Flores et al., 2002).
Tobacco Use and Exposure Among Hispanic and Latino Populations
The Hispanic and Latino populations in the United States face unique challenges that put them at higher risk than the general population for tobacco use and exposure to smoke:
- Depending on location, about one fifth of Hispanic or Latino persons have low English-language skills (U.S. Census Bureau, 2004).
- The Hispanic and Latino populations are likely to have limited exposure to anti-tobacco use information, educational materials, media messages, and cessation services, compared with those who have better English-language skills.
- The Hispanic and Latino populations continue to be the target of intensive tobacco-industry marketing efforts. These efforts include sponsorship of cultural events, funding of Hispanic and Latino organizations and issues, and other targeted marketing efforts.
- Initial evidence suggests that Hispanic and Latino workers tend to be more exposed than other workers to secondhand smoke on the job. This increased exposure occurs even though Hispanic and Latino populations often demonstrate high levels of awareness of the health risks posed by secondhand smoke, as well as strong support for smoke-free policies.
- As Hispanic and Latino persons become more acculturated, initial findings suggest that their rate of smoking is increasing and approaching that of the general population. This trend is of particular concern with regard to younger people.
Several issues pertain directly to the design and implementation of successful tobacco control programs in the Hispanic and Latino population assessed with the H/L ATS:
- Prevalence of "occasional," or nondaily, smoking.
- Increase in use of menthol cigarettes.
- Prevalence of smoking cessation and quit attempts.
- Methods used to quit, including nontraditional methods possibly unique to Hispanic/Latino persons.
- Rules and perceptions about secondhand smoke exposure in the home and at work.
- Additional demographic considerations (e.g., country of birth, education and income levels, length of stay in the United States).
Hispanic and Latino communities have unique strengths and assets conducive to effective tobacco control initiatives. By acting now to help these communities implement sustained, culturally appropriate tobacco control interventions, researchers and health practitioners can avert the predicted rise in smoking and the associated danger of smoking-related disease.
F.1.2 Design of the H/L ATS Questionnaires and Survey Methodology
CDC convened a meeting of leading researchers and health program administrators, "Effective Tobacco Control in Hispanic/Latino Communities," in August 2002. The purpose of this meeting was to address questions about tobacco control specifically as it relates to program, policy, communication, surveillance, and evaluation in various Hispanic and Latino populations. The subsequent findings and recommendations specific to surveillance needs assisted in the development of the H/L ATS. Recommendations that directly influenced the development of the H/L ATS included the following:
- Increase sample sizes to generate more precise estimates of tobacco use prevalence in Hispanic and Latino populations.
- Collect information on secondhand smoke exposure rates and on attitudes toward public policy.
- Appropriately adapt, both culturally and linguistically, survey questions for the Hispanic/Latino population.
- Monitor the prevalence of and trends in "occasional smoking" among Hispanic and Latino populations.
- Collect data at the regional and state levels.
- Track and analyze the effects of acculturation, income levels, and education levels on tobacco use prevalence and behaviors among Hispanic and Latino populations.
- Conduct research on whether differences in tobacco use prevalence between specific Hispanic/Latino populations are due to differences in culture or to differences in class and income (or socioeconomic) status.
- Examine the reasons for disparities among various Hispanic/Latino populations.
During the meeting, strong consensus emerged that tobacco control interventions that acknowledge and highlight the cultural strengths, assets, and protective factors of the Hispanic and Latino population would be most effective. Conversely, it was agreed that interventions that failed to recognize the unique linguistic, social, and cultural characteristics of this population would be relatively ineffective.
During the August 2002 meeting, 10 researchers reviewed the OSH General Population State Adult Tobacco Telephone Survey. These 10 researchers were selected for the review of the survey instrument because of their expertise in tobacco control and their research experience with specific Hispanic and Latino subpopulations (e.g., Mexican American, Puerto Rican, and Cuban). The researchers advised OSH which questions were appropriate and which were inappropriate for Hispanic and Latino populations.
Five of the original 10 researchers were subsequently identified to provide more in-depth recommendations on how to adapt the survey for the Hispanic and Latino population. A second meeting was held at CDC, where the five researchers and an OSH epidemiologist continued to modify the General Population State ATS to make the questions more culturally appropriate for Hispanic and Latino subgroups. In addition, new questions specific to Hispanic and Latino populations were added to the instrument, such as the following: "In the past 12 months, have you seen a medicine man (curandero), santero, spiritist (espiritista), herbalist (yerbero), religious leaders (priest, pastor, rabbi, etc.), or other non– health professionals to help you quit smoking?" New demographic questions also elicit country of birth, educational levels, income levels, and language preference.
The H/L ATS is meant to be readily usable by public health organizations at all levels. The H/L ATS can be administered either as a telephone interview or as an in-person interview, and in English or Spanish.7 Two of the case studies described in Section C use telephone administration, and the third uses in-person interviewing. Each of the case studies selected the administration mode that best suited its particular study population. To further increase the usability of the H/L ATS, complementary survey materials (i.e., screeners, consent forms, and advance letters in both English and Spanish) were developed as part of the H/L ATS package.8 All materials are publicly available to jurisdictions, organizations, and individuals.
- The H/L ATS questionnaire and screener are available in three versions: all English, all Spanish, and Spanish with English instructions for interviewers and programmers. The designers of the H/L ATS have anticipated that the survey may be used in countries where Spanish is the national language. The "all Spanish" version is appropriate when all interviewers, programmers, and survey staff are Spanish monolinguals. The "Spanish with English instructions" version is appropriate when it is expected that those programming the computerized version of the questionnaire will be English monolinquals.
- The consent form and consent text provided here differ slightly from those used in CDC's 2007 survey.
F.1.3 Development of Spanish Versions of the H/L ATS
Consensus Approach to Translation
Committee approaches to translation have been used since the 1960s (Nida, 1964) and more recently in the translation of data collection instruments (Acquadro, Jambon, Ellis, & Marquis, 1996; Brislin, 1976; Guillemin, Bombardier, & Beaton, 1993; Schoua-Glusberg, 1992). Moreover, the Census Bureau guideline for survey translation now recommends this approach (U.S. Census Bureau, 2004). Its strength is that consensus among bilinguals produces more accurate text than the subjective opinion of a single translator: problems of personal idiosyncrasies, culture, and uneven skill in either language are overcome. Translation by committee produced the Spanish version of the H/L ATS.
The core modules of the H/L ATS were originally translated into Spanish by an epidemiologist within OSH. This translation underwent review by a team of three translators who are native speakers of some of the main varieties of Spanish spoken in the United States (Mexican, Puerto Rican, and South American). This review was refereed by a specialist with 2 decades of experience in chairing survey translation committees. For the supplemental modules, there existed no original Spanish translation. The team of three translators worked independently, translating from English one third of the protocol each. After this initial translation, another refereed reconciliation meeting was held to ensure each item reflected the intent of the English original and was equally effective in Spanish.
In reconciliation meetings, each translator contributed to the discussion to improve and refine the translation, in order to make the Spanish culturally appropriate for the three majority Latino or Hispanic populations. In the discussions, each member was required to articulate the reasons for suggested changes or improvements to the original translation. The team looked together for alternative translations, finally selecting by consensus.
Cognitive Research to Enhance Cultural Adaptation
Upon completion of the translations, the questionnaires were subjected to extensive cognitive testing with members of the target populations residing in Miami, New York City, El Paso, and Chicago. Cognitive testing was conducted to establish that the questions are culturally appropriate and sensible; that they will be understood similarly across participants of different national origins, education levels, or income levels; and that the Spanish translation works well across such a diversity of respondents. As is the case in every cognitive evaluation project, a goal was also to identify any question-processing problems or difficulties respondents might experience—including cognitive complexity of questions, words not understood, problems in stems or response categories, and recall issues—that could lead to measurement error.
Cognitive interviews are a qualitative method that determines not only which items work and which present problems, but also why certain items do not work. Because they are bilingual, translators are systematically different from the monolingual (and often monocultural) population for whom the translated instrument is prepared. With the use of such qualitative methods, the generation of a translated text brings together, at each stage of the process, the combined efforts of professional translators and the input of the audience.
Sixty-eight interviews—19 in English, and 49 in Spanish—were conducted in two rounds, between June 2004 and April 2005 (Table F-1). Recruiting for interviews was accomplished through community organizations and agencies in each city.
|Origin and residence||Spanish interviews||English interviews|
Findings from the first round of interviews were used to make changes intended to reduce or eliminate problems and error. In the second round, these changes were tested. The current, final version of the English and Spanish H/L ATS includes the modifications stemming from both rounds of cognitive interviews. The resulting version is suitable for the broader Latino population of the United States.
F.2 References and Resources
F.2.1 Background to Hispanic/Latino Surveying and the ATS
- Flores G, Fuentes-Afflick E, Barbot O, Carter-Pokras O, Claudio L, Lara M, et al. The health of Latino children: urgent priorities, unanswered questions, and a research agenda. Journal of the American Medical Association 2002;288(1):82–90.
- Kerner J, Breen N, Tefft M, Silsby J. Tobacco use among multi-ethnic Latino populations. Ethnicity & Disease 1998;8(2):167–183.
- Mariolis M. Guidelines for Conducting General Population State Adult Tobacco Surveys. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; in press.
- U.S. Census Bureau. U.S. Census Report: Language Use and English Speaking Ability [PDF–482 KB]. Available at http://www.census.gov/prod/2003pubs/c2kbr-29.pdf.
- Waksberg J, Levine D, Marker D. Assessment of Major Federal Data Sets for Analyses of Hispanic and Asian or Pacific Islander Subgroups and Native Americans: Extending the Utility of Federal Data Bases. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2000. Available at http://aspe.hhs.gov/hsp/minority-db00/task3/section2.htm.
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- Brislin R. Introduction. In: Brislin R, editor. Translation: Applications and Research. New York: Gardner; 1976.
- Brodie M, Steffenson A, Valdez J, Levin R, Suro R. 2002 National Survey of Latinos. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2002. Washington, DC: Pew Hispanic Center. Available at http://www.kff.org/kaiserpolls/20021217a-index.cfm.
- Carley-Baxter L, Link MW, Roe D, Quiroz RS. Does context really matter? Results from a Spanish language advance letter pilot. Presentation to the American Association for Public Opinion Research (AAPOR) conference, Montreal, Canada, May 2006.
- Dillman DA. Mail and Internet Surveys: The Tailored Design Method. New York: Wiley; 2000.
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- Erkut S, Alarcon O, Garcia CC, Tropp LR, Vazquez Garcia HA. The "dual focus" approach to creating bilingual measures. Journal of Cross-Cultural Psychology 1999;30:206–218.
- Gallagher PM, Fowler FJ, Stringfellow VL. Hablamos español: collecting information by mail from Spanish-speaking Medicaid enrollees. Paper presented to the American Association of Public Opinion Research (AAPOR) conference, St. Petersburg Beach, FL, May 1999.
- Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. Journal of Clinical Epidemiology 1993;46:1417−1432.
- Harris-Kojetin LD, Fowler FJ, Brown JA, Schnaier JA, Sweeny SF. The use of cognitive testing to develop and evaluate CAHPS 1.0 core survey items. Medical Care 1999;37:MS10–MS21.
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- McKay RB, Breslow MJ, Sangster RL, Gabbard SM, Reynolds RW, Nakamoto JM, et al. Translating survey questionnaires: lessons learned. New Directions in Evaluation 1996;70:93–104.
- Morales LS, Weidmer BO, Hays RD. Readability of CAHPS 2.0 Child and Adult Core Surveys. In: M. Cynamon M, Kulka R, editors. Seventh Conference on Health Survey Research Methods. Hyattsville, MD: U.S. Department of Health and Human Services; 2001:83–90.
- Nida EA. Toward a Science of Translating. Leiden, Netherlands: Brill; 1964.
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- Schoua-Glusberg A. Report on the Translation of the Questionnaire for the National Treatment Improvement Evaluation Study. Chicago: National Opinion Research Center; 1992.
- Schoua-Glusberg A. Screening households in Chicago: Latino cooperation rate in the Project on Human Development in Chicago Neighborhoods (PHDCN). Poster session presented at Hearing the Unheard: Interviewing Minorities, University of Nebraska Survey Research Center 2nd Annual Symposium, Lincoln, April 1998.
- Schoua-Glusberg A. Privacy, Census and Surveys: Latinos' Views: Final Report for Protecting Privacy Project Contract Research. Washington, DC: U.S. Department of Commerce, Census Bureau; 2000.
- U.S. Census Bureau. Census Bureau Guideline: Language Translation of Data Collection Instruments and Supporting Materials [PDF–482 KB]. Washington, DC: U.S. Department of Commerce, Census Bureau; 2004. Available at http://www.census.gov/srd/papers/pdf/rsm2005-06.pdf.
- Weech-Maldonado R, Weidmer BO, Morales LS, Hays RD. Cross-cultural adaptation of survey instruments: the CAHPS experience. In: Seventh Conference on Health Survey Research Methods [PDF–4.8 MB]. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2000:75–82. Available at http://www.cdc.gov/nchs/data/conf/conf07.pdf.
F.2.3 Sampling and Weighting
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- American Association of Public Opinion Research (AAPOR). Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Lenexa, KS: AAPOR; 2004.
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- Kalsbeek WD. Sampling minority groups in health surveys. Statistics in Medicine 2003;22:1527–1549.
- Kalsbeek WD, Agans RP. Sampling and weighting in household telephone surveys. In: Lepkowski JM, et al., editors. Advances in Telephone Survey Methodology. New York: Wiley; 2007.
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- Waksberg J, Levine D, Marker D. Assessment of Major Federal Data Sets for Analyses of Hispanic and Asian or Pacific Islander Subgroups and Native Americans: Extending the Utility of Federal Data Bases. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2000. Available at http://aspe.hhs.gov/hsp/minority-db00/task2/index.htm.
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F.2.4 Analysis and Reporting
- Americans for Nonsmokers' Rights (ANRF). States and Municipalities with 100% Smokefree Laws in Workplaces, Restaurants, or Bars. [PDF–129 KB] Available at http://www.no-smoke.org/pdf/WRBLawsMap.pdf.
- Brownson RC, Hopkins DP, Wakefield MA. Effects of smoking restrictions in the workplace. Annual Review of Public Health 2002;23:333–348.
- Clark PI, Gardiner PS, Djordjevic MV, Leischow SJ, Robinson RG. Menthol cigarettes: setting the research agenda. Nicotine & Tobacco Research 2004;6(Suppl. 1):S5–S9.
- Fleiss JL, Levin B, Paik MC. Statistical Methods for Rates and Proportions. 3rd edition. New York: Wiley; 2003.
- Giovino GA, Sidney S, Gfroerer JC, O'Malley PM, Allen JA, Richter PA, et al. Epidemiology of menthol cigarette use. Nicotine & Tobacco Research 2004;6(Suppl. 1):S67–S81.
- Mowery PD, Farrelly MC, Haviland ML, Gable JM, Wells HE. Progression to established smoking among US youths. American Journal of Public Health 2004;94(2):331–337.
- Nazaroff WW, Singer BC. Inhalation of hazardous air pollutants from environmental tobacco smoke in US residences. Journal of Exposure Analysis and Environmental Epidemiology 2004;14(Suppl. 1):S71–S77.
- Pirkle JL, Flegal KM, Bernert JT, Brody DJ, Etzel RA, Maurer KR. Exposure of the US population to environmental tobacco smoke: the Third National Health and Nutrition Examination Survey, 1988 to 1991. Journal of the American Medical Association 1996;275(16):1233–1240. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in smoke-free workplace policies among food service workers. Journal of Occupational and Environmental Medicine 2004;46(4):347–356.
- U.S. Census Bureau. Current Population Survey, February, June, and November 2003: Tobacco Use Supplement Technical Documentation CPS-03 [CD-ROM]. Washington, DC: Marketing Services Office, Customer Services Center, U.S. Bureau of the Census; 2006. Available at http://riskfactor.cancer.gov/studies/tus-cps/index.html.
- U.S. Department of Health and Human Services (USDHHS). The Health Benefits of Smoking Cessation: A Report of the Surgeon General. Rockville, MD: USDHHS, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1990. USDHHS Publication No. [CDC] YO-K-116.
- U.S. Department of Health and Human Services (USDHHS). Tobacco Use Among U.S. Racial/Ethnic Minority Groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta, GA: USDHHS, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1998.
- U.S. Department of Health and Human Services (USDHHS). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: USDHHS, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006.
F.2.5 Enhancing Response Rates
- Albright V. Current methodological issues in telephone interviewing. Presentation to the annual meeting of Bay Area Survey Evaluators, Researchers, and Statisticians, University of California, Berkeley, September 2003.
- Albright V, Bye L. Integrating priority populations into comprehensive surveillance and evaluation systems: California's LGBT Population Survey. Paper presented at the 2003 National Conference on Tobacco or Health Conference, Boston, MA, May 2003.
- American Association of Public Opinion Research (AAPOR). Resources for Researchers. 2006. Available at http://www.aapor.org/resources.
- U.S. Department of Health and Human Services (USDHHS). Effective Tobacco Control in Hispanic/Latino Communities: A Synopsis of Key Findings and Recommendations. Atlanta, GA: USDHHS, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.
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