M. Diane McKee

Health-related functional status in pregnancy : Relationship to depression and social support in a multi-ethnic population

Objective To describe perceived well-being and functional status during uncomplicated late pregnancy among low-income minority women, and to examine the relationship of functional status to depression and social support. Methods Hispanic and black women with low-risk pregnancies completed an interview consisting of demographics, the Medical Outcomes Study Short Form 36 (SF-36), Beck Depression Inventory-II (BDI-II), and the Norbeck Social Support Questionnaire. Results Of the 155 women who were eligible and asked to participate, 41 refused for a participation rate of 74%. Results of the SF-36 showed lowest perceived well-being in the vitality and physical role dimensions. Depressive symptomatology was high, with a mean BDI score of 15 (standard deviation 8.6). Using a BDI score of 14 as the cutoff point, over half of the sample was categorized as having significant depressive symptoms. Significantly lower functional status was seen for depressed subjects in all subscales of the SF-36 compared with nondepressed subjects. Although functional status was negatively correlated with BDI score in all dimensions (r = .23–.69), correlation of SF-36 scores with social support was much weaker (r = .06–.24). Conclusion Elevated levels of depressive symptomatology are strongly correlated with lowered health-related functioning and perceived well-being. Social support is not associated with increased physical or emotional well-being but is weakly associated with mental health as measured by the SF-36.

Depression and negative life events among pregnant african-american and hispanic women

Depression, social support, and life events were assessed in a sample of African-American and Hispanic women (N = 148) with uncomplicated pregnancies. Over half (51%) showed elevated depressive symptoms. Overall, women had fewer social supports and more negative life events than found in previous studies. African-Americans had more practical social support and persons in their support networks than Hispanics. Over a third of the sample (37%) had lost an important person in the past year. Depressed women reported more negative events than nondepressed women. Many negative life events and few social supports place minority women at risk for prenatal depression.

Adapting Psychosocial Intervention Research to Urban Primary Care Environments: A Case Example

PURPOSE We wanted to describe the unique issues encountered by our research team in testing an intervention to reduce perinatal depression in real-world community health centers. METHOD We used a case study of an experience in conducting a randomized controlled trial designed to test the effectiveness of a low-cost multimodal psychosocial intervention to reduce prenatal and postpartum depression. Low-income minority women (N = 187) with low-risk pregnancies were randomly assigned to the intervention or treatment as usual. Outcomes of interest were depressive symptoms and social support assessed at 3 months’ postpartum. RESULTS Our intervention was not associated with changes in depressive symptoms or social support. Challenges in implementation were related to participant retention and intervention delivery. Turnover of student therapists affected continuity in participant-therapist relationships and created missed opportunities to deliver the intervention. The academic-community partnership that was formed also required more involvement of health center personnel to facilitate ownership at the site level, especially for fidelity monitoring. While attentive to cultural sensitivity, the project called for more collaboration with participants to define common goals and outcomes. Participatory research strategies could have anticipated barriers to uptake of the intervention and achieved a better match between outcomes desired by researchers and those of participants. CONCLUSION Several criteria for future research planning emerged: assessing what the population is willing and able to accept, considering what treatment providers can be expected to implement, assessing the setting’s capacity to accommodate intervention research, and collecting and using emerging unanticipated data.

Nonprescribed antimicrobial drugs in Latino community, South Carolina.

We investigated in a sample of Latinos the practices of antimicrobial drug importation and use of nonprescribed antimicrobial drugs. In interviews conducted with 219 adults, we assessed health beliefs and past and present behaviors consistent with acquiring antimicrobial drugs without a prescription in the United States. Many (30.6%) believed that antimicrobial drugs should be available in the United States without a prescription. Furthermore, 16.4% had transported nonprescribed antimicrobial drugs into the United States, and 19.2% had acquired antimicrobial agents in the United States without a prescription. A stepwise logistic regression analysis showed that the best predictors of having acquired nonprescribed antimicrobial drugs in the United States were beliefs and behavior consistent with limited regulations on such drugs. Many persons within the Latino community self-medicate with antimicrobial drugs obtained without a prescription both inside and outside the United States, which adds to the reservoir of antimicrobial drugs in the United States.

Health Care Seeking Among Urban Minority Adolescent Girls: The Crisis at Sexual Debut

PURPOSE We wanted to explore the context of help seeking for reproductive and nonreproductive health concerns by urban adolescent girls. METHODS We undertook a qualitative study using in-depth interviews of African American and Latina girls (n = 22) aged 13 to 19 years attending public high schools in the Bronx, NY. RESULTS Before the onset of sexual activity, most girls meet health needs within the context of the family, relying heavily on mothers for health care and advice. Many new needs and concerns emerge at sexual debut. Key factors modulating girls’ ability to address their health needs and concerns include (1) the strategy of selective disclosure of information perceived to be harmful to close family relationships or threaten privacy; (2) the desire for personalized care, modeled on the emotional and physical care received from mother; and (3) relationships with physicians that vary in quality, ranging from distant relationships focused on providing information to close continuity relationships. Core values shaping these processes include privacy, a close relationship with the mother, and a perception of sexual activity as dangerous. No girl was able to meet her specific reproductive health needs within the mother-daughter relationship. Some find nonmaternal sources of personalized health care and advice for reproductive health needs, but many do not. CONCLUSIONS Adolescent girls attempt to meet reproductive health needs within a context shaped by values of privacy and close mother-daughter relationships. Difficulty balancing these values often results in inadequate support and care.

Prenatal and Postpartum Depression among Low-Income Dominican and Puerto Rican Women

This longitudinal study examined depression symptoms among pregnant, low-income, urban Latinas, primarily Puerto Ricans and Dominicans, receiving obstetrical services in community health centers. In all, 106 women were interviewed in late pregnancy, 47 were interviewed again 2 to 3 weeks postpartum, and 42 three months postpartum. Elevated levels of depressive symptoms were evident in 53% of the original sample. Across time, depressive symptoms decreased significantly; however, a decreased score was strongly related to number of negative life events. Social support scores were minimally related to depressive symptomatology. Service recommendations based on these findings include conducting third-trimester assessments of life events experienced during the past year and screening for depression to better identify women at risk of late pregnancy to postpartum–persistent depressive symptoms. More research and clinical attention on dysphoric states in pregnant Latinas and understanding the consequences of impaired perinatal mental health on maternal well-being and infant outcomes are needed.

Women's experiences of abnormal cervical cytology: illness representations, care processes, and outcomes.

BACKGROUND We wanted to explore the conceptual representations of illness and experiences with care among women who have learned of an abnormal Papanicolaou (Pap) smear result. METHODS The study took place in 2 primary care, family practice clinics serving low-income, multiethnic patients in the Bronx, New York City. We conducted qualitative, semistructured telephone interviews with 17 patients who had recently learned of abnormal findings on a Pap smear. After a preliminary coding phase, the investigators identified 2 important outcomes: distress and dissatisfaction with care, and factors affecting these outcomes. A model was developed on a subset of the data, which was then tested on each transcript with an explicit search for disconfirming cases. A revised coding scheme conforming to the dimensions of the model was used to recode transcripts. RESULTS Women reported complex, syncretic models of illness that included both biomedical and folk elements. Many concerns, especially nonbiomedical concerns, were not addressed in interactions with physicians. An important source of both distress and dissatisfaction with care was the women’s lack of understanding of the inherent ambiguity of Pap smear results. When perceived care needs, which included emotional support as well as information, were not met, distress and dissatisfaction were greatly increased. CONCLUSION In this study, patients’ illness models and expectations of care were not routinely addressed in their conversations with physicians about abnormal Pap smear results. When physicians can take the time to review patients’ illness models carefully, distress and dissatisfaction with care can be reduced considerably.

New york city physicians' views of providing long-acting reversible contraception to adolescents.

PURPOSE Although the US adolescent pregnancy rate is high, use of the most effective reversible contraceptives—intrauterine devices (IUDs) and implantable contraception—is low. Increasing use of long-acting reversible contraception (LARC) could decrease adolescent pregnancy rates. We explored New York City primary care physicians’ experiences, attitudes, and beliefs about counseling and provision of LARC to adolescents. METHODS We conducted in-depth telephone interviews with 28 family physicians, pediatricians, and obstetrician-gynecologists using an interview guide based on an implementation science theoretical framework. After an iterative coding and analytic process, findings were interpreted using the capability (knowledge and skills), opportunity (environmental factors), and motivation (attitudes and beliefs) conceptual model of behavior change. RESULTS Enablers to IUD counseling and provision include knowledge that nulliparous adolescents are appropriate IUD candidates (capability) and opportunity factors, such as (1) a clinical environment supportive of adolescent contraception, (2) IUD availability in clinic, and (3) the ability to insert IUDs or easy access to an someone who can. Factors enabling motivation include belief in the overall positive consequences of IUD use; this is particularly influenced by a physicians’ perception of adolescents’ risk of pregnancy and sexually transmitted disease. Physicians rarely counsel about implantable contraception because of knowledge gaps (capability) and limited access to the device (opportunity). CONCLUSION Knowledge, skills, clinical environment, and physician attitudes, all influence the likelihood a physician will counsel or insert LARC for adolescents. Interventions to increase adolescents’ access to LARC in primary care must be tailored to individual clinical practice sites and practicing physicians, the methods must be made more affordable, and residency programs should offer up-to-date, evidence-based teaching.

“You Have to Give Her That Confidence” Conversations About Sex in Hispanic Mother-Daughter Dyads

The considerable risk of negative consequences of unprotected intercourse underscores a need to better understand how Latina adolescent girls acquire the skills to manage the risks associated with sexuality. The authors used in-depth qualitative interviews with mothers and their daughters to examine communication related to sexuality with the goal of understanding the sociocultural and family context of Latina adolescents’ sexual behavior and reproductive health care seeking. Mothers and daughters agree that sexual activity threatens girls’ health and future and that open communication about sexuality is highly valued but difficult to achieve. Communication content tends to focus on the threats of sexual activity, but process is important. Strategies of effective communicators include deliberate creation of an atmosphere of approachability and a flow of information from daughter to mother.

Effectiveness of a Risk Screener in Identifying Hepatitis C Virus in a Primary Care Setting

OBJECTIVES We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers. METHODS A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ(2) test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener. RESULTS Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified. CONCLUSIONS A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.