Patterns of missing data in ethnic minority health research: a survey project with Russian-speaking immigrant women with hypertension.

We explored cultural-level variables and their associations with missing data in a group of immigrants from the Former Soviet Union (FSU). Elderly hypertensive women (N 5 105) completed a health survey. Prevalence of missing data and z scores were calculated to determine which survey items and measures were more likely to have missing data. Hierarchical linear regressions were performed to test whether cultural variables predicted the rate of missing data beyond individual variables. Culture variables associated with survey nonresponse and missing data were related to depression, anxiety, medication beliefs and practices, attitudes toward physicians, and cultural and behavioral identity. An interpretation of the patterns of missing data and strategies to reduce the likelihood of missing data in this population are discussed. Cultural norms likely influence patients' orientations toward their health care providers. Providers would do well to normalize difficulties with medical adherence and encourage patients to ask questions about such directives. We rec- ommend that researchers consider the cultural appropriateness of survey items and consider alternative methods (i.e., qualitative designs) for culturally sensitive topics such as mental health and sexuality.Keywords: missing data; Russian immigrants; hypertension; health behaviors; cultureVarious survey design and statistical methods exist to reduce and handle missing data (e.g., reduction of survey length, simplification of item word- ing, listwise deletion, single imputation, multiple imputation; Curran, Bacchi, Schmitz, Molenberghs, & Sylvester, 1998; El-Masri & Fox-Wasylyshyn 2005; Fielding, Fayers, Loge, Jordhoy, & Kaasa, 2006). Furthermore, certain par- ticipant characteristics (e.g., gender, age, education, and marital status; Kjoller & Thoning, 2005; Korkeila et al., 2001; Peyre, Coste, & Leplege, 2010; Tolonen et al., 2006) have been identified as factors, consistent across cultures, that likely affect rates of missing data. Yet, a gap still exists between the literature related to the statistical treatment of missing data and that which identifies how cultural factors (i.e., goals, beliefs, and attitudes shared by a group of people; Heine, 2012), above and beyond participant characteristics and survey design, influence nonresponse. Inappropriate treatment of missing data presents serious limitations in analysis and interpretation and calls into question the validity of research findings. Ethnic minorities and those with more severe illness are more likely to have missing survey data (Fairclough, Peterson, & Chang, 1998; Steffen et al., 2008), thereby increasing the likelihood of data misinterpretation for these populations. A more comprehensive understanding of the factors that contribute to missing data can improve our ability to collect meaningful and valid data on underserved popula- tions such as immigrant groups.According to ecological theory (Bronfenbrenner, 1979), individuals' behaviors and interactions within and between multiple systems, including that of health systems, are culturally mediated. That is to say, social scripts, family expectations and relation- ships, cultural identity development, and acculturation (i.e., language, medication and health care use beliefs) influence individuals' personal health behaviors and health care orientations (Chng, Wong, Park, Edberg, & Lai, 2003; Ivanov & Buck, 2002; Musa, Schulz, Harris, Silverman, & Thomas, 2009; Shtarkshall, Baynesan, & Feldman, 2009). As such, health-related behaviors occur within a particular cultural context and must be interpreted within that context (Hoopman, Terwee, Muller, Ory, & Aaronson, 2009; Wiium & Wold, 2009). For example, researchers have found that the way in which providers (i.e., physicians, nurses, and medical social workers) communicate with patients and the beliefs they have about patients of a distinct cultural system can dissuade those patients from seeking health care (Shtarkshall et al. …