Global Health Journal Club February 25, 2004 Erin R. Suydam

1. Global Health Journal Club February 25, 2004 Erin R. Suydam Protective Strength Factors, Resources, and Risks in Relation to Depressive Symptoms among Childbearing Women of Mexican Descent Heilemann, MarySue V., et al. Health Care for Women International, 25:88-106, 2004.

2. Background Info • Latinos are the fastest-growing ethnic group in the U.S. • Of the 32.8 million Latinos in the U.S., 66% are of Mexican descent • Highest fertility rate of all racial or ethnic groups in the U.S.

3. Other studies have examined: • Risk factors: low income, low educational attainment, increased barriers to care, exposure to physical violence, and substance use • Protective factors and resources: social support, positive attitudes towards pregnancy, and gestational week at initiation of prenatal care

4. Other studies have shown: • Acculturation is associated with perinatal complications – excessive weight gain, sexually transmitted diseases, alcohol, drug and cigarette use • Acculturated Latinos deal with more emotional and psychological distress in the U.S. due to alienation, discrimination, and U.S. values of individualism and self-reliance counter to Mexican values of family and community integration

5. Why do this study? • Depression in perinatal Latinas • Intragroup comparisons • Strength factors • External resources • Acculturation

6. Aims of study • #1 - Determine relationship between acculturation and depressive symptoms • #2 - Determine relationship between acculturation and strength, extrinsic, and risk factors • #3 - Determine relationship between depressive symptoms and strength, extrinsic, and risk factors

7. Data analysis • Reliability • Instruments must measure consistently across participants • Correlation coefficient • .60-.80 for attitude scales • Internal consistency • Participant’s selection of one item consistently relates to selection of all other items • Cronbach alpha coefficient • .70 for established, .60 for new instruments

8. Acculturation • Place of birth • Language preference • Exposure to the U.S. in childhood • Allows for intragroup analysis

9. Sample • Urban northern California setting – family health community clinics and dual-immersion language school • Between 21 and 40 years of age • Read and write in Spanish or English • 59 pregnant women • 70 women within 6 months of last pregnancy

10. CES-D scale • Center for Epidemiological Studies – Depression Scale • 20 items designed to measure frequency of depressive symptoms in the general population • 0-60 with a threshold score of 16 representing the upper 20% of mean scores • Threshold score of 24 representing upper 20% of mean scores of immigrant women of Mexican descent • Very high risk • Fatigue common in pregnancy and postpartum period

11. My appetite was poor I could not shake off the blues I had trouble keeping my mind on what I was doing I felt depressed My sleep was restless I felt sad I could not get going Nothing made me happy I felt like a bad person I lost interest in my usual activities I slept much more than usual I felt like I was moving too slowly I wanted to hurt myself I felt fidgety I wished I was dead I was tired all the time I did not like myself I lost a lot of weight without trying to I had a lot of trouble getting to sleep I could not focus on the important things CES-D Scale 0 Rarely/None = less than 1 day 2 Occasionally = 3 to 4 days 1 Some/a little = 1 to 2 days 3 Most/All the time = 5 to 7 days

12. Intrinsic Strength Factors • Sense of mastery • 5 items • “I have little control over the things that happen to me” • “There is little I can do to change many of the important things in my life” • “There is really no way I can solve some of the problems that I have” • “Sometimes I feel that I am being pushed around in life” • “I often feel helpless in dealing with the problems of life” • 4-point (strongly agree, agree, disagree, strongly disagree) scale • Resilience • 2 subscales • “Personal competence” - 17 items represent self-reliance, independence, determination, invincibility, master, and perseverance • “Acceptance of self and life” - 6 items represent adaptability, flexibility, and a balanced perspective of life • Only instrument with a Cronbach alpha coefficient less than .60 • Influenced by limited number of items

13. Intrinsic Strength Factors (cont.) • Life satisfaction • 0 (“very dissatisfied”) to 7 (“very satisfied”): “Overall, how satisfied are you with life?” • Importance of spiritual beliefs • 0 (“not important”) to 7 (“very important”): “How important are your spiritual beliefs to you?”

14. Extrinsic Resource Factors • Education • Employment • Income • Number of adults in the household • Partner status • Number of people who lived on reported family income • Financial resources adequate to meet needs during previous month? • Access to a car

15. Risk Variables • Alcohol use • Smoking • Caffeine intake • Cocaine, marijuana, crack, speed, and other street drugs

16. Sample Statistics • 69 preferred to read and write in Spanish and 60 preferred English • 77 were born in Mexico and 52 were born in the U.S. • 82% partnered, 10% single, 8% separated, divorced or widowed • Gross monthly household income of 57% was less than $1250 • 42% did not complete high school, 33.5% completed high school/GED, and 24.5% attended vocational school or college

17. Depressive Symptoms • Mean CES-D score was 18.3 • 56% scored 16 or higher • 31% scored 24 or higher • 51% of pregnant women scored 16 or higher and 25% 24 or higher • 59% of postpartum women scored 16 or higher and 36% 24 or higher

18. Acculturation and Depression - #1 • 52% of pregnant women and 73% of postpartum women were exposed to the U.S. in childhood • Reported a significantly higher level of depressive symptoms than those who spent their childhood in Mexico - #1 • No difference when compared by birthplace or language preference

19. Acculturation and Strength, External and Risk Factors - #2 • Exposure to the U.S. in childhood • Lower life satisfaction • Access to a car • Cigarette use • Alcohol use

20. Depression and Intrinsic Strength Factors - #3 • CES-D scores were inversely related to mastery and life satisfaction in all women • Inversely related to resilience and importance of spiritual beliefs for postpartum women only

21. Depression and External Resource Factors - #3 • No significant differences between pregnant and postpartum women • 74.4% of postpartum women who reported inadequate financial resources to meet needs scored higher than 16 on CES-D • Number of adults in the household was inversely correlated with depressive symptoms

22. Depression and Risk Factors - #3 • No significant associations between a CES-D score of 16 or higher and alcohol, cigarette, street drug, or caffeine use

23. Results • Exposure to the U.S. in childhood, a poor sense of mastery, and dissatisfaction with life were more related to depressive symptom experience than childbearing status or more traditional demographic variables such as age, income, or education

24. Discussion • Mean CES-D score similar to mean score in other studies • Similar CES-D scores in perinatal period to all other women in larger study • Early exposure to the U.S. brought deleterious effects on women’s health and well-being related to depressive symptoms

25. Intrinsic Strength Factors • Mastery and life satisfaction may have protective effects as resources to help withstand potentially harmful or distressing social experiences • Associated with higher birth weight, active support providers in a family setting, lower anxiety and less vulnerability to social environments

26. Extrinsic Resource Factors • Support from adults in the household affected women regardless of partner status

27. Limitations • Cross-sectional design restricts understanding of dynamic nature of relationships between culture, context, events and depressive symptoms • Convenience sample not representative

28. Implications • Strategies for assessment, screening and diagnosis of depression, including the CES-D, in routine care • Pregnant and postpartum women of Mexican descent who grew up in the U.S. or who live alone in the U.S. particularly at risk • Strategies to enhance mastery among childbearing women to lower depressive symptoms