Utility of a goodness-of-fit index for the graded response model with small sample sizes : a Monte Carlo investigation.

Item response theory (IRT) is expanding to diverse research settings, without accompanying access to easily implemented model fit methods. One simple model fit approach involves x2/df ratios. However, its utility is not known across several conditions salient to recent applied IRT research. A Monte Carlo simulation was implemented to investigate the effects of several factors (sample size, adjustment condition, type of misfit, and proportion of misfitting items) on x2/df ratios in the context of the Graded Response Model. Results suggested that: (a) adjusted x2/df ratios were appropriate for the largest sample size condition (N=10000), but were extremely inflated for small (N=400) and medium (N=1500) conditions; (b) x2/df ratios were differentially affected across sample sizes by type and amount of misfit; and (c) sensitivity of the x2/df\u3e 3 cut point for identifying misfit in single items was notably low across all study conditions. Implications, limitations, and future directions are discussed

Improving screening for externalizing behavior problems in very young children : applications of item response theory to evaluate instruments in pediatric primary care.

Externalizing behavior problems in very young children are associated with an array of negative and costly long-term outcomes. Pediatric primary care is a promising venue for implementing screening practices to improve early identification of this social and public health problem. In this setting, screening requires a brief, easily scored instrument which can detect sub-clinical to clinical levels of the latent construct within the context of early childhood development. Further, items used should perform consistently with children of all sociodemographic backgrounds. This study applied item response theory analyses to investigate the precision, utility, and differential item functioning (DIF) of items measuring externalizing behavior problems in two caregiverreport questionnaires: the PSC-17 (Gardner et al., 1999) and the BPI (Peterson & Zill, 1986; Zill, 1990). Caregivers (N = 900) of children ages 3 to 5 responded to both instruments and a sociodemographic questionnaire in the waiting rooms of four pediatric primary care clinics. Sociodemographic characteristics of the children were diverse: 47% were female, 50% were of minority race, and 43% were of low socioeconomic status (SES). Eighteen items comprising the instruments\u27 combined externalizing subscales were evaluated for (a) levels of externalizing behavior problems best measured, and (b) DIF exhibited by child sex, race, and SES. Samejima\u27s (1969) graded response model was fit to the data, and two methods of DIF-detection were employed. Estimation of item parameters allowed consideration of the levels of externalizing behavior problems at which each item was most informative. Five items were found to measure only low to average levels of externalizing problems in the target population, while the remaining 13 were informative at sub-clinical to clinical levels. Significant DIF was detected in 8 of 18 items by child sex, race, or SES. A set of 4 items was identified which (a) provided the most information at sub-clinical to clinical levels of externalizing behavior problems, and (b) exhibited the least amount of DIF by child sex, race, and SES. These items may constitute a promising tool for screening purposes with preschool-aged children in the primary care setting, potentially improving early identification of very young children with externalizing behavior problems

Evaluation of Multi-Level Barriers and Facilitators in a Large Diabetic Retinopathy Screening Program in Federally Qualified Health Centers: A Qualitative Study

BACKGROUND: Recommended annual diabetic retinopathy (DR) screening for people with diabetes has low rates in the USA, especially in underserved populations. Telemedicine DR screening (TDRS) in primary care clinics could expand access and increase adherence. Despite this potential, studies have observed high variability in TDRS rates among clinics and over time, highlighting the need for implementation supports. Previous studies of determinants of TDRS focus on patients\u27 perspectives, with few studies targeting upstream multi-level barriers and facilitators. Addressing this gap, this qualitative study aimed to identify and evaluate multi-level perceived determinants of TDRS in Federally Qualified Health Centers (FQHCs), to inform the development of targeted implementation strategies. METHODS: We developed a theory-based semi-structured interview tool based on the Consolidated Framework for Implementation Research (CFIR). We conducted 22 key informant interviews with professionals involved in TDRS (administrators, clinicians, staff). The interviews were audio-recorded and transcribed verbatim. Reported barriers and facilitators were organized into emergent themes and classified according to CFIR constructs. Constructs influencing TDRS implementation were rated for each study site and compared across sites by the investigators. RESULTS: Professionals identified 21 main barriers and facilitators under twelve constructs of the five CFIR domains. Several identified themes were novel, whereas others corroborated previous findings in the literature (e.g., lack of time and human resources, presence of a champion). Of the 21 identified themes, 13 were classified under the CFIR’s Inner Setting domain, specifically under the constructs Compatibility and Available Resources. Themes under the Outer Setting domain (constructs External Incentives and Cost) were primarily perceived by administrators, whereas themes in other domains were perceived across all professional categories. Two Inner Setting (Leadership Engagement, Goals and Feedback) and two Process (Champion, Engaging) constructs were found to strongly distinguish sites with high versus low TDRS performance. CONCLUSIONS: This study classified barriers and facilitators to TDRS as perceived by administrators, clinicians, and staff in FQHCs, then identified CFIR constructs that distinguished high- and low-performance clinics. Implementation strategies such as academic detailing and collection and communication of program data and successes to leadership; engaging of stakeholders through involvement in implementation planning; and appointment of intervention champions may therefore improve TDRS implementation and sustainment in resource-constrained settings

Colorectal Cancer Prevention: Perspectives of Key Players from Social Networks in a Low-Income Rural US Region

Social networks influence health behavior and health status. Within social networks, “key players” often influence those around them, particularly in traditionally underserved areas like the Appalachian region in the USA. From a total sample of 787 Appalachian residents, we identified and interviewed 10 key players in complex networks, asking them what comprises a key player, their role in their network and community, and ideas to overcome and increase colorectal cancer (CRC) screening. Key players emphasized their communication skills, resourcefulness, and special occupational and educational status in the community. Barriers to CRC screening included negative perceptions of the colonoscopy screening procedure, discomfort with the medical system, and misinformed perspectives on screening. Ideas to improve screening focused on increasing awareness of women\u27s susceptibility to CRC, providing information on different screening tests, improving access, and the key role of health-care providers and key players themselves. We provide recommendations to leverage these vital community resources

A Randomized Controlled Trial of a Faith-Placed, Lay Health Advisor Delivered Smoking Cessation Intervention for Rural Residents

Introduction. Rural US residents smoke at higher rates than urban or suburban residents. We report results from a community-based smoking cessation intervention in Appalachian Kentucky. Study design. Single-blind, group-randomized trial with outcome measurements at baseline, 17 weeks and 43 weeks. Setting/participants. This faith-placed CBPR project was located in six counties of rural Appalachian Kentucky. A total of 590 individual participants clustered in 28 churches were enrolled in the study. Intervention. Local lay health advisors delivered the 12-week Cooper/Clayton Method to Stop Smoking program, leveraging sociocultural factors to improve the cultural salience of the program for Appalachian smokers. Participants met with an interventionist for one 90 min group session once per week incorporating didactic information, group discussion, and nicotine replacement therapy. Main outcome measures. The primary outcome was self-reported smoking status. Secondary outcomes included Fagerström nicotine dependence, self-efficacy, and decisional balance. Results. With post-intervention data from 92% of participants, those in intervention group churches (N = 383) had 13.6 times higher odds of reporting quitting smoking one month post-intervention than participants in attention control group churches (N = 154, p \u3c 0.0001). In addition, although only 3.2% of attention control group participants reported quitting during the control period, 15.4% of attention control participants reported quitting smoking after receiving the intervention. A significant dose effect of the 12-session Cooper/Clayton Method was detected: for each additional session completed, the odds of quitting smoking increased by 26%. Conclusions. The Cooper/Clayton Method, delivered in rural Appalachian churches by lay health advisors, has strong potential to reduce smoking rates and improve individuals\u27 health

Female Sexual Function Index Short Version: A MsFLASH Item Response Analysis

The Female Sexual Function Index (FSFI) is a psychometrically sound and popular 19-item self-report measure, but its length may preclude its use in studies with multiple outcome measures, especially when sexual function is not a primary endpoint. Only one attempt has been made to create a shorter scale, resulting in the Italian FSFI-6, later translated into Spanish and Korean without further psychometric analysis. Our study evaluated whether a subset of items on the 19-item English-language FSFI would perform as well as the full-length FSFI in peri- and post-menopausal women. We used baseline data from 898 peri- and post-menopausal women recruited from multiple communities, ages 42–62 years, and enrolled in randomized controlled trials for vasomotor symptom management. Goals were to (1) create a psychometrically sound, shorter version of the FSFI for use in peri- and post-menopausal women as a continuous measure and (2) compare it to the Italian FSFI-6. Results indicated that a 9-item scale provided more information than the FSFI-6 across a spectrum of sexual functioning, was able to capture sample variability, and showed sufficient range without floor or ceiling effects. All but one of the items from the Italian 6-item version were included in the 9-item version. Most omitted FSFI items focused on frequency of events or experiences. When assessment of sexual function is a secondary endpoint and subject burden related to questionnaire length is a priority, the 9-item FSFI may provide important information about sexual function in English-speaking peri- and post-menopausal women

Validity of Recall of Tobacco Use in Two Prospective Cohorts

This project studied the convergent validity of current recall of tobacco-related health behaviors, compared with prospective self-report collected earlier at two sites. Cohorts were from the Oregon Research Institute at Eugene (N = 346, collected 19.5 years earlier) and the University of Pittsburgh, Pennsylvania (N = 294, collected 3.9 years earlier). Current recall was examined through computer-assisted interviews with the Lifetime Tobacco Use Questionnaire from 2005 through 2008. Convergent validity estimates demonstrated variability. Validity estimates of some tobacco use measures were significant for Oregon subjects (age at first cigarette, number of cigarettes/day, quit attempts yes/no and number of attempts, and abstinence symptoms at quitting; all P < 0.03). Validity estimates of Pittsburgh subjects’ self-reports of tobacco use and abstinence symptoms were significant (P < 0.001) for all tobacco use and abstinence symptoms and for responses to initial use of tobacco. These findings support the utility of collecting recalled self-report information for reconstructing salient lifetime health behaviors and underscore the need for careful interpretation

Identifying Unbiased Items for Screening Preschoolers for Disruptive Behavior Problems

Objective: Efficient identification and referral to behavioral services are crucial in addressing early-onset disruptive behavior problems. Existing screening instruments for preschoolers are not ideal for pediatric primary care settings serving diverse populations. Eighteen candidate items for a new brief screening instrument were examined to identify those exhibiting measurement bias (i.e., differential item functioning, DIF) by child characteristics. Method: Parents/guardians of preschool-aged children (N = 900) from four primary care settings completed two full-length behavioral rating scales. Items measuring disruptive behavior problems were tested for DIF by child race, sex, and socioeconomic status using two approaches: item response theory-based likelihood ratio tests and ordinal logistic regression. Results: Of 18 items, eight were identified with statistically significant DIF by at least one method. Conclusions: The bias observed in 8 of 18 items made them undesirable for screening diverse populations of children. These items were excluded from the new brief screening tool