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ETHNOGERIATRICS AND SPECIAL

POPULATIONS

Determining Prevalence and Correlates of Elder Abuse Using


Promotores: Low-Income Immigrant Latinos Report High Rates
of Abuse and Neglect
Marguerite DeLiema, BS,* Zachary D. Gassoumis, BSc,* Diana C. Homeier, MD,† and Kathleen H.
Wilber, PhD*

Low-income Latino immigrants are understudied in elder Key words: Hispanic/Latino; incidence; elder abuse;
abuse research. Limited English proficiency, economic inse- elder mistreatment; elder neglect
curity, neighborhood seclusion, a tradition of resolving
conflicts within the family, and mistrust of authorities may
impede survey research and suppress abuse reporting.
To overcome these barriers, promotores, local Spanish-
speaking Latinos, were recruited and trained to interview a
sample of Latino adults aged 66 and older residing in
low-income communities. The promotores conducted
door-to-door interviews in randomly selected census tracts C urrent research suggests that more than one in 10
adults aged 60 and older are victims of elder abuse
every year,1 yet only a small proportion of the estimated
in Los Angeles to assess the frequency of psychological,
physical, and sexual abuse; financial exploitation; and 5 million cases of noninstitutional elder abuse annually are
caregiver neglect. Overall, 40.4% of elderly Latino adults reported to Adult Protective Services (APS), the state agen-
had experienced some form of abuse or neglect within the cies charged with investigating abuse. Risk factors for
previous year. Nearly 25% reported psychological abuse, abuse include low income, low education, living with
10.7% physical assault, 9% sexual abuse, and 16.7% others, isolation, and less use of formal services.1,2 These
financial exploitation, and 11.7% were neglected by their characteristics are prominent in Latino immigrants,
caregivers. Younger age, higher education, and experienc- suggesting that they may be a group that is particularly
ing sexual or physical abuse before age 65 were significant vulnerable. In 2010, Latinos made up 6.7% of the U.S.
risk factors for psychological, physical, and sexual abuse. population aged 65 and older,3 up from 5.0% in 2000.4
Years lived in the United States, younger age, and prior Of Latino older adults, 55.0% were immigrants, 41.1%
abuse were associated with greater risk of financial exploi- had limited English proficiency, and 20.4% lived below
tation. Years spent living in the United States was a signifi- the federal poverty level.5
cant risk factor for caregiver neglect. Abuse prevalence Cultural norms indicate that immigrant Latinos may
was much higher in all mistreatment domains than findings be less likely to identify as victims of abuse for several rea-
from previous research on community-dwelling elderly sons. Older Latinos often reside with their families and
adults, suggesting that low-income Latino immigrants are rely on them for long-term care.6 Although close kin net-
highly vulnerable to elder mistreatment or that respon- works and values of filial responsibility have been found
dents are more willing to disclose abuse to promotores to be protective,7,8 familism, which emphasizes the needs
who represent their culture and community. J Am Geriatr of the family over the needs of the individual, may conceal
Soc 60:1333–1339, 2012. mistreatment and inhibit formal help-seeking.8,9 Preserving
la familia to avoid vergüenza, or shame, promotes
tolerance of family violence and suppresses reporting.7,8
Citizenship status may also be a barrier if undocumented
From the *Davis School of Gerontology, University of Southern Latinos are less likely to report abuse for fear of deporta-
California, Los Angeles, California; and †Keck School of Medicine,
tion of themselves or their family members.7,9 General
University of Southern California, Los Angeles, California.
mistrust of government could exacerbate these fears,10 and
Address correspondence to Marguerite DeLiema, Davis School of
limited English proficiency may inhibit reporting even
Gerontology, University of Southern California, 3715 McClintock Ave,
Los Angeles, CA 90089. E-mail: riparett@usc.edu when fears are overcome. Furthermore, cultural beliefs
about the acceptability of sharing money and resources
DOI: 10.1111/j.1532-5415.2012.04025.x

JAGS 60:1333–1339, 2012


© 2012, Copyright the Authors
Journal compilation © 2012, The American Geriatrics Society 0002-8614/12/$15.00
1334 DELIEMA ET AL. JULY 2012–VOL. 60, NO. 7 JAGS

among family members9 and economic interdependence employing promotores for a number of health-related pro-
within extended families may blur the boundaries of finan- grams in the Latino community. A community partner
cial exploitation, especially in households where the only recruited three promotores who had recently completed
reliable source of income is the elderly adult’s benefits 240 hours of training; the fourth interviewer was their
(e.g., Social Security, Supplemental Security Income (SSI)). supervisor. Two days of additional training were provided
Recently, several population-based studies have sys- that covered protocols for screening potential respondents
tematically explored the prevalence and correlates of elder for participation, ensuring informed consent, and adminis-
mistreatment in domestic settings in the United States. A tering the questionnaire. The training included practice
nationally representative study11 of 3,005 adults aged 57 administering the instrument to a bilingual member of the
to 85 (6.8% Latino) found past-year prevalence rates of team. Promotores were provided with community resource
9.0% for psychological aggression, <1% for physical packets to give to each participant and were trained to
assault, and 3.5% for financial exploitation. Participants help respondents identify appropriate services if the inter-
were informed that incidents of abuse would be disclosed view suggested such a need. After a review of California’s
to their state’s reporting hotline, including personal identi- statutes defining mandated reporters for elder abuse16 and
fying information. Latinos were the racial and ethnic consultation with the study’s 13-member advisory commit-
group least likely to acknowledge being abused. A nation- tee, it was determined that promotores did not qualify as
wide telephone survey of community-residing adults aged mandatory reporters. Although they did not collect any
60 and older (N = 5,777) (4.3% Latino) found the follow- personally identifiable information from respondents (e.g.,
ing 1-year prevalence rates:12 4.6% psychological, 1.6% name, address, telephone number), promotores were
physical, 0.6% sexual, 5.2% financial, and 0.5% caregiver instructed to contact APS or law enforcement directly if
neglect. Respondents who were of Latino or Hispanic eth- they encountered respondents who faced immediate
nicity were not independently associated with higher rates danger. To maximize reliability and ensure consistency in
of abuse in any of these domains. (This article uses the survey administration, regular debriefing sessions were
term Latino in place of Hispanic; despite important differ- conducted with promotores, their bilingual supervisor, and
ences—Latinos include all those of Latin American des- a bilingual member of the research team.
cent, whereas Hispanic includes those of Spanish descent The study aimed to measure the prevalence of abuse
while excluding Brazilians—the two terms are generally and neglect among Spanish-speaking Latinos aged 65 and
treated synonymously.) older and residing in predominantly low-income, racial and
Although national prevalence studies have included ethnic minority neighborhoods in Los Angeles. Because the
Latinos, it is possible that those hardest to reach—low- survey asked about abuse prevalence in the previous
income, non-English-speaking immigrants—may have been 12 months, eligible individuals were aged 66 and older.
underrepresented. Possible barriers include challenges with Participants were determined to have capacity to provide
accessing Latino immigrants living in ethnically segregated informed consent based on a modified version of the Evalu-
communities, lack of trust impeding disclosure of sensitive ation to Sign Consent form.17 In an effort to maximize reli-
information, and cultural norms of keeping problems ability, this study did not interview proxies for cognitively
within the family. Furthermore, Latinos are less likely to impaired participants unable to provide consent.
have access to landline telephones according to research by The population of Los Angeles County (9.8 million) is
the National Center for Health Statistics.13 separated into eight geographic Service Planning Areas
Given the potential of underrepresenting low-income (SPAs). From among the 705 block groups in SPA 6, six
Latino immigrants, the goal of this study was twofold. block groups were randomly selected that included at least
First, it sought to identify the overall prevalence of five 100 residents using Summary File 1 data from the 2000
types of elder abuse in a sample of community-residing U.S. Census. From February to June 2010, promotores
immigrant Latinos. Second, it examined correlates of abuse went door to door within the selected block groups to
and compared these with national prevalence studies. identify residents who met inclusion criteria and request
their participation. Based on considerable demographic
shifts within SPA 6 since the 2000 census, concentrations
METHODS
of elderly Latino adults were far from the levels expected,
so study researchers worked with the promotores to iden-
Sample and Interview Protocol
tify three additional survey areas in late May to reach the
Research suggests that face-to-face recruitment in high- target sample of 200 respondents. Individuals encountered
density Latino neighborhoods is the most-effective method outside their homes who met inclusion criteria were also
of recruiting the target population.14 Therefore, monolin- interviewed. Promotores offered potential participants $10
gual Spanish-speaking promotores were employed to to participate. Those who agreed (N = 200) were asked to
conduct door-to-door interviews. Traditionally, the role of give oral consent. Two participants’ records were later
promotores, Latino community health workers, is to pro- excluded because of missing data.
vide culturally sensitive linkages between communities and Promotores used tracking forms to identify those who
health and social services. More recently, promotores have declined to participate. Based on a sample of these track-
been recognized as an effective tool in research to collect ing forms, the study’s response rate was conservatively
data in hard-to-reach populations.15 In the current study, estimated at 65%. Interviews lasted approximately 60 to
promotores were recruited through a partnership with a 90 minutes; all were conducted in Spanish. The University
local agency that serves the target area. The agency had of Southern California institutional review board approved
well over a decade of experience hiring, training, and the study.
JAGS JULY 2012–VOL. 60, NO. 7 ELDER ABUSE IN LATINO COMMUNITIES 1335

Measures and Variables Measures of Vulnerability


Elder abuse prevalence was measured in the aggregate and Because it causes greater dependency on caregivers, physi-
within five subtypes: psychological aggression, physical cal impairment is commonly cited as a risk factor for elder
assault, sexual coercion, financial exploitation, and care- abuse and neglect.21,22 Using a previously validated
giver neglect. Surveys were conducted using a 63-item scale,23 six ADL and six IADL impairments were com-
abuse instrument developed for the study, the University bined into a needs-based impairment scale (range 0–12;
of Southern California Older Adult Conflict Scale (USC- a = 0.74). Lack of social support also increases risk of
OACS). The instrument included questions derived from abuse,1,2,22 so five questions were derived from the UCLA
the Revised Conflict Tactics Scales18 and the Conflict Tac- Loneliness Scale.24 These questions were summed to yield
tics Scales for Older Adults (UC Irvine, National Institutes a total social isolation score (range = 0–5; a = 0.67), with
of Health Grant R21AG028060) with permission from 0 indicating the lowest level of social isolation and five
both sources. Input was sought from older adult focus representing the highest level of isolation. Several studies
groups conducted in English and Spanish and a multidisci- have indicated that prior abuse is another risk factor for
plinary group of experts. Two members of the research abuse.1,25 Therefore, after the physical and sexual abuse
team first constructed the instrument in English and sections, a global question was asked about the experience
translated it into Spanish from different Latin American of abuse in each of these domains before age 65.
countries of origin, to avoid the inclusion of words or
phrases unique to any region. The three promotores and
Statistical Analysis
two supervisors then reviewed it to identify areas that
could be restated to provide clarity and avoid misinterpre- Prevalence was measured using frequencies for each of the
tation. The instrument was pilot tested in English with five five types of abuse, separated into mild and severe, and
volunteers aged 65 and older, followed by cognitive inter- they were aggregated to assess overall prevalence of abuse
views with 12 participants aged 65 and older from a senior and neglect. Logistic regression analysis was used to iden-
center. These two steps helped to ensure that the language tify the factors associated with abuse and neglect. Because
was easily understandable and that the participants inter- of their conceptual similarity as willful actions intended to
preted the questions as intended. Advisory committee meet- cause physical or emotional harm, psychological aggres-
ings were held quarterly to provide community input on sion, physical assault, and sexual coercion were combined
the instrument and the approach to data collection. into a single conflict domain (a = 0.91). For conflict abuse
The USC-OACS included nine items of psychological and financial exploitation, participants were considered
aggression (a = 0.80), 15 of physical assault (a = 0.85), victims of abuse and assigned a value of 1 if they
and four of sexual coercion (a = 0.65). To identify care- responded affirmatively to one or more of the items within
giver neglect (12 items), need for assistance with activities the domain. A similar approach was used for neglect, with
of daily living (ADL) and instrumental activities of daily participants considered victims of neglect if they indicated
living (IADL) were first asked about, and then those who any one or more ADL or IADL impairments for which a
needed assistance were asked whether adequate support potential caregiver was present but not meeting their
was provided (a = 0.76). Financial exploitation was mea- needs. Neglect was incorporated into the total prevalence
sured using 14 items (a = 0.49). To minimize the pressure rate for elder abuse and neglect, but the denominator for
of social desirability, each mistreatment section was neglect used in the regression model included only those
prefaced with statements that conveyed acceptance and who needed caregiver support (as indicated by self-
normalized the questions that followed.19 Survey items reported ADL or IADL impairment) and therefore had the
asked about concrete abusive behaviors, designed to potential to be neglected. Independent variables in the
prompt closed-ended responses. For example, “Did some- logistic regression analysis were age, sex, education
one close to you threaten to put you in a nursing home [in (dichotomized at completing ninth grade, the end of com-
the last 12 months]?” For all five abuse areas, promotores pulsory education in Mexico), years lived in the United
asked whether these behaviors had happened in the last States, marital status, living arrangement (condensed to
12 months (yes or no) and, if so, how often. Participants three categories: living alone, living with children/grand-
were considered victims of mistreatment if they endorsed children, and all others), functional impairment (excluded
any item within a particular domain. Based on convention, from the neglect model), physical or sexual abuse before
psychological, physical, and sexual abuse were classified as age 65, and social isolation. Cases with missing data on
minor or severe depending on the type of behavior18 and the independent variables were included in the analysis
previous work was drawn on to extend this classification sample, and all available data were analyzed in Mplus
paradigm to financial abuse;20 neglect severity was 6.11 (Muthén & Muthén, Los Angeles, CA) using the full-
determined based on the degree to which the elderly information maximum likelihood approach.26
adult’s needs were unmet on each domain. Promotores
also collected sociodemographic data, including age, sex,
RESULTS
race and ethnicity, country of origin, years in the United
States, living arrangement, marital status, level of educa- Forty percent (n = 198) indicated that they had experi-
tion, and employment status. A question regarding enced at least one type of abuse; 21% had experienced
whether individual monthly income exceeded $902 multiple types. As shown in Table 1, mean age was 72,
(California’s SSI threshold at the time) was excluded from 56% were female, 50% were married or partnered, 13%
analyses because 49% did not answer. were single, and 20% were widowed. One-third lived
1336 DELIEMA ET AL. JULY 2012–VOL. 60, NO. 7 JAGS

Table 1. Sample Characteristics Table 2. Presence of Abuse According to Domain and


Severity
Characteristic Value
Any Severe
Age, mean ± SD (n = 194) 72.3 ± 6.9 Abuse Domain n Abuse % Abuse %
Female,% (n = 192) 56.3
Hispanic, Latino, or Spanish origin,% (n = 192) 99.5 Total 198 40.4 22.7
Country of birth,% (n = 198) Conflict abuse 198 30.7 13.6
United States 5.1 Psychological 198 24.8 10.6
Mexico 64.1 Physical 197 10.7 5.6
El Salvador 15.7 Sexual 189 9.0 1.6
Guatemala 10.6 Financial abuse 180 16.7 10.6
Other Spanish or Latin country 4.5 Caregiver neglect 197 11.7 2.0
Years lived in United States, 30.9 ± 17.1
mean ± SD (n = 194)
Highest level of education,% (n = 176) Specific Prevalence Findings
<High school 86.9
High school or GED equivalent 8.5 As shown in Table 2, nearly 25% reported psychological
Some college 2.3 abuse (14.2% minor, 10.6% severe). Of the 10.7% that
College graduate 2.3 indicated physical abuse, half reported at least one incident
Years of education 4.4 ± 3.1 of severe physical assault. Nine percent reported sexual
(if <high school), mean ± SD (n = 151) abuse (1.6% severe), 16.7% reported financial exploitation
Marital status,% (n = 196) (10.6% severe), and 11.7% reported caregiver neglect. Of
Single 13.3
these, 83% suffered from minor neglect (caregiver some-
Married or partnered 50.5
Widowed 20.4
times provided assistance), and 17% indicated severe
Divorced or separated 15.8 neglect. Six percent reported having impairments with no
Living arrangement,a % (n = 195) caregiver available to help. In the combined conflict
Alone 17.4 domains, 30.7% reported one or more incident of psycho-
With spouse 33.3 logical, physical, or sexual abuse (minor or severe). Three
With child or children 46.7 study respondents (1.5%) indicated that they had reported
With grandchild or grandchildren 5.1 abuse of any kind to APS in the last year.
With sibling or other relative 14.9
With friend 4.1
Work status,a % (n = 192) Correlates of Abuse
Retired 50.0
Paid employment 10.4 Table 3 presents the logistic regression for conflict and
Volunteer 8.9 financial abuse (n = 198) and for neglect among those
Homemaker 31.8 who needed caregiver assistance (n = 59). In the combined
Monthly income,% >$902 (n = 101) 10.9 conflict domain, age was inversely related (odds ratio (OR)
Average monthly income, $, 344.32 ± 365.39 =0.90, P = .007), and education was positively related
mean ± SD (n = 60) (OR = 5.58, P < .001). Functional impairment tended to
Physical or sexual abuse before 23.8
age 65,% (n = 193)
be associated with higher levels of abuse, but the effect
Functional impairment, % was not significant (OR = 1.28, P = .05). Physical and sex-
Activities of daily living (n = 196) 15.8 ual abuse before age 65 had a strong relationship with
Instrumental activities of daily living (n = 195) 24.6 conflict abuse after age 65 (OR = 13.1, P < .001). Prior
abuse was also related to higher odds of financial exploita-
SD = standard deviation; GED = general equivalence diploma. tion (OR = 2.93, P = .02). Age (OR = 0.92, P = .07) and
a
Participant could choose multiple responses within the category. years lived in the United States (OR = 1.02, P = .08)
tended to be associated with financial exploitation, but
their effects were not significant. For caregiver neglect,
with a spouse, 46% lived with children or grandchildren, only years lived in the United States was significant
and 17% lived alone. Ninety-five percent were immi- (OR = 1.05, P = .02).
grants, primarily from Mexico (64%), with an average
age at immigration of 41 ± 18. Only 13% had graduated
DISCUSSION
from high school or earned a general educational devel-
opment equivalent. Of those remaining, average educa- The high rates of abuse, neglect, and financial exploitation
tion was 4.4 years; only 20% of the sample had in this sample (40.4% total; 22.7% severe) exceed those
completed at least a ninth-grade education. Of those who reported in previous community-based studies. There are
reported income (n = 101), 89% indicated <$902/month. several explanations for these striking findings. First, the
Twenty-five percent indicated at least one IADL limita- sample may represent a particularly high-risk subset of the
tion, 16% reported at least one ADL limitation, and Latino population that has been underrepresented in elder
70% were not impaired. On a scale of 0 to 5, the mean abuse research. Challenges faced by this community—
level of self-perceived loneliness/isolation was 1.8 ± 0.7. limited English proficiency, economic insecurity, neighbor-
Twenty-three percent reported physical or sexual abuse hood seclusion, fear of crime, mistrust of authorities—may
before age 65. present barriers to survey research and suppress abuse
JAGS JULY 2012–VOL. 60, NO. 7 ELDER ABUSE IN LATINO COMMUNITIES 1337

Table 3. Estimates of Logistic Regression Analysis of Selected Covariates with Conflict Abuse (Combined Psycho-
logical, Physical, and Sexual Abuse), Financial Abuse, and Caregiver Neglect
Conflict Abuse Financial Abuse Caregiver Neglect

Independent Variable Odds Ratio (95% Confidence Interval) P-Value

Sociodemographic characteristic
Age 0.90 (0.84–0.97) .007 0.92 (0.85–1.01) .07 1.00 (0.91–1.10) .94
Sex (female = 1) 1.45 (0.62–3.41) .39 0.71 (0.28–1.80) .47 1.52 (0.29–8.08) .62
>9th grade education 5.58 (2.08–14.98) <.001 2.13 (0.82–7.18) .12 1.30 (0.23–7.52) .77
Years lived in United States 1.00 (0.97–1.02) .80 1.02 (1.00–1.05) .08 1.05 (1.01–1.09) .02
Married or partnered 1.34 (0.56–3.22) .51 1.26 (0.47–3.36) .65 2.00 (0.41–9.71) .39
Living arrangement (reference other)
Living alone 1.02 (0.29–3.57) .98 0.91 (0.25–3.28) .89 0.45 (0.05–4.13) .48
Living with children or grandchildren 2.01 (0.81–5.01) .13 1.41 (0.53–3.79) .49 1.78 (0.45–7.01) .41
Functional impairment 1.28 (1.00–1.65) .05 1.10 (0.82–1.47) .53
Personal characteristic
History of abuse 13.1 (5.24–32.83) <.001 2.93 (1.18–7.30) .02 1.31 (0.29–5.88) .73
Isolation 0.64 (0.35–1.19) .16 0.63 (0.30–1.29) .20 0.45 (0.15–1.31) .14

N = 198 for conflict abuse; N = 180 for financial abuse; N = 59 for caregiver neglect (impaired participants only).

reporting. The approach of going door to door within the Based on population statistics from the 2010 U.S.
target neighborhoods may have recruited Latinos who do Census30 and the analysis of data obtained from Los Ange-
not typically participate in studies of elder mistreatment. les County, approximately 2.0% of the residents within
Second, it is possible that a hidden population was the target community of SPA 6 made a report to APS in
not captured, but rather that the interview method uncov- the year before the final survey was administered (July
ered abuse that is often concealed. Respondents may have 2009–June 2010). This number is close to the 1.5% of
felt more comfortable discussing mistreatment with respondents who indicated reporting abuse of any kind to
promotores who represent their culture and community. APS in the year before taking the survey but significantly
Furthermore, promotores did not collect identifying lower than abuse rates detected using the USC-OACS
information and were not mandated to report abuse, instrument. This comparison suggests that Latino immi-
potentially increasing willingness to disclose. To the grants considerably underreport mistreatment, perhaps
knowledge of the authors, no new reports of abuse were because of a cultural tendency to resolve conflict within
filed as a result of the survey, despite offers from promot- the family or from fear that contacting authorities consti-
ores to assist respondents. tutes a greater risk to the victim and the family.
Third, the instrument may have been more sensitive or
the threshold may have been lower than other studies. Com-
Correlates of Abuse
paring the USC-OACS with the telephone survey used in a
previous study revealed that both instruments assess similar Consistent with existing research,1 it was found that the
abusive behaviors, although the telephone survey combines risk of conflict abuse decreases with age. The finding that
them into a single item (e.g., “Has anyone ever hit you with conflict abuse is higher in those with more education con-
their hand or object, slapped you, or threatened you with a tradicts earlier research.2 It was also found that respon-
weapon?”).12 The USC-OACS asks about each behavior dents who had lived longer in the United States faced a
separately, potentially capturing a wider range of harmful higher risk of caregiver neglect. Although the underlying
experiences. Further validation and psychometric testing reasons are not apparent from this study, these associa-
with other populations is needed to determine whether the tions suggest that Latinos who are more acculturated to
USC-OACS is more sensitive to mistreatment. the United States and more educated are more likely to
Few studies have examined the prevalence of elder acknowledge abuse.
abuse in Latin America; of them, the only studies that the Experiencing physical or sexual abuse before age 65
authors are aware of that used large community-based was a considerable risk factor for mistreatment. This find-
samples took place in Mexico. In 2007, a study of 1,078 ing informs the debate that some elder abuse is domestic
rural Mexican elderly adults reported an overall abuse abuse that persists into old age.21 These findings support
prevalence of 8.1%.27 A second study reported a past-year previous research that suggests that types of elder abuse
abuse prevalence of 16% in urban-dwelling elderly emerging in older age, particularly financial exploitation
Mexican adults.28 As with the current study’s findings, and neglect, are associated with different vulnerabilities,
psychological mistreatment was the most commonly including functional and cognitive impairment.31,32
reported abuse type, yet the overall frequency was much
higher in the current study. Higher rates of abuse from
Limitations and Future Research
smaller studies have been reported in other Latin American
countries,29 but prevalence findings in Mexico are more Several caveats should be noted when considering these
consistent with nationally representative surveys conducted findings. First, the study focused on a specific population
in the United States.1 within a specific geographic region of Los Angeles County.
1338 DELIEMA ET AL. JULY 2012–VOL. 60, NO. 7 JAGS

As such, the goal was to provide greater detail about a supported the data collection and analysis reported in this
group that may be underrepresented in national studies, manuscript.
but results may not generalize to all Latinos. Second, Author Contributions: DeLiema: analysis and interpre-
although there are trade-offs with any survey approach, tation of data and drafting and revision of manuscript.
because of their cultural knowledge, it is likely that Gassoumis: acquisition, analysis, and interpretation of data
promotores obtained a higher response rate and perhaps and revision of manuscript. Homeier: conception and
more-valid results. This should be tested by comparing the design of study and revision of manuscript. Wilber: con-
use of promotores with other survey methods. Because ception and design of study; acquisition, analysis, and
promotores worked off site in a community-based agency, interpretation of data; and drafting and revision of manu-
it was important to ensure that they were well trained and script. All authors approved the manuscript as submitted.
acquainted with the goals of the study. Sponsor’s Role: The sponsor had no role in the design,
The instrument had good internal consistency with the methods, participant recruitment, data collections, analy-
exception of financial exploitation. In analyzing responses, sis, or preparation of paper.
it appears that some items were less relevant in this popu-
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