S. Darius Tandon

A comparison of three screening tools to identify perinatal depression among low-income African American women

BACKGROUND The purpose of the current study was to determine the sensitivity, specificity, and positive predictive value of three depression screening tools among a low-income African American population of pregnant and recently delivered women enrolled in home visitation programs in a low-income urban community. METHODS Ninety-five women enrolled in home visitation programs-32 who were pregnant and 63 with a child <6 months comprise the study sample. Each woman completed a structured clinical interview and three depression screening tools-the Edinburgh Postnatal Depression Scale (EPDS), Center for Epidemiologic Studies Depression Scale (CES-D), and Beck Depression Inventory II (BDI-II). RESULTS Over a quarter of women (28.4%) were experiencing major depression. Each screening tool was highly accurate in detecting major depression and major or minor depression among prenatal and postpartum women, with areas under the curve (AUCs) >0.90. Sensitivities of all screening tools were improved when using cutoffs lower than those considered standard by instrument developers. LIMITATIONS Participants were recruited from home visitation programs in an urban context which may limit generalizability to other populations of low-income African American women. Given that no women during pregnancy met criteria for minor depression, it was not possible to determine optimal prenatal cutoff scores. CONCLUSIONS Three depression screening tools-the EPDS, CES-D, and BDI-II-appear to be reliable and brief assessments of major and minor depression among low-income African American perinatal women. Providers using these tools should consider using lower cutoff scores to most effectively identify women in need of depression treatment.

Examining Maternal Depression and Attachment Insecurity as Moderators of the Impacts of Home Visiting for At-Risk Mothers and Infants

Home visiting programs for at-risk mothers and their infants have proliferated nationally in recent years, yet experimental studies of home visiting have yielded mixed findings. One promising strategy for explicating the effects of early home visiting is to examine moderators of program impacts. This study assessed the roles of maternal depression and attachment insecurity as moderators of the impacts of Healthy Families Alaska home visiting services for at-risk mothers and their infants. At-risk families (N = 325) were randomly assigned to home visiting or community services as usual (n = 162 and 163, respectively). Maternal depression and attachment insecurity (attachment anxiety and discomfort with trust/dependence) were measured at baseline. Maternal psychosocial and parenting outcomes were measured when children were 2 years old via maternal self-report, observation, and review of substantiated reports of child maltreatment. Maternal depression and attachment insecurity interacted in their moderation of program impacts. For several outcomes, home visiting impacts were greatest for nondepressed mothers with moderate-to-high discomfort with trust/dependence and for depressed mothers with low discomfort with trust/dependence. Implications for practice and policy are discussed.

Preventing Perinatal Depression in Low-Income Home Visiting Clients: A Randomized Controlled Trial.

OBJECTIVE To assess the efficacy of a 6-week cognitive-behavioral intervention in preventing the onset of perinatal depression and reducing depressive symptoms among low-income women in home visitation programs. METHOD Sixty-one women who were pregnant or who had a child less than 6 months of age and who were assessed as at risk for perinatal depression were randomized to a 6-week, group-based cognitive-behavioral intervention or usual home visiting services. Study participants were predominately African American, unmarried, and unemployed. Intervention sessions were led by a licensed clinical social worker or clinical psychologist. Home visitors provided 1-on-1 reinforcement of key intervention messages between group sessions. Depressive symptoms were measured with the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996), and major depressive episodes were measured with the Maternal Mood Screener (MMS; Le & Muñoz, 1998). Outcomes were assessed at baseline and at 1 week and 3 months postintervention. RESULTS Repeated measures analysis of variance indicated that there was a significant Time × Condition interaction, F(2, 112) = 4.1, p = .02. At 3 months postintervention, 9 of 27 (33%) women receiving usual care reported levels of depressive symptoms that met clinical cutoff for depression on the MMS compared with 3 of 32 (9%) women in the intervention condition, χ²(1, N = 59) = 5.18, p < .05. CONCLUSION This study provides preliminary data on the efficacy of a cognitive-behavioral intervention to prevent perinatal depression among home visiting clients and suggests it is feasible to embed such an intervention in home visitation programs. A larger trial is warranted to attempt to replicate study findings.

A systematic review of home-based interventions to prevent and treat postpartum depression

This systematic review evaluated randomized controlled trials assessing home-based psychological interventions to prevent and treat postpartum depression (PPD). Six studies meeting inclusion criteria were identified, five assessing treatments for PPD and one assessing a preventive intervention for PPD. Interventions used cognitive behavioral, psychodynamic, and non-directive counseling approaches. Of the six studies reviewed, four reported statistically significant treatment effects on PPD following the intervention. Each of the three types of psychological interventions were shown to reduce levels of maternal depression. Recommendations for future development and evaluation of home-based psychological interventions for PPD are discussed. These include identification of mediators and moderators of intervention efficacy, exploring strategies for prevention of PPD, and targeting high-risk groups.

Using Community-Based Participatory Research as a Guiding Framework for Health Disparities Research Centers

There has been growing interest in conducting community-based health research using a participatory approach that involves the active collaboration of academic and community partners to address community-level health concerns. Project EXPORT (Excellence in Partnerships, Outreach, Research, and Training) is a National Center for Minority Health and Health Disparities (NCMHD) initiative focused on understanding and eliminating health disparities for racial and ethnic minorities and medically underserved populations in the United States. The New York University (NYU) Center for the Study of Asian American Health (CSAAH) is 1 of 76 Project EXPORT sites. This paper describes how CSAAH developed partnerships with varied Asian American community stakeholders as a first step in establishing itself as a Project EXPORT center that uses community-based participatory research (CBPR) as its orienting framework. Three guiding principles were followed to develop community–academic partnerships: (1) creating and sustaining multiple partnerships; (2) promoting equity in partnerships; and (3) commitment to action and research. We discuss strategies and action steps taken to put each principle into practice, as well as the successes and challenges we faced in doing so. Developing community–academic partnerships has been essential in our ability to conduct health disparities research in Asian American communities. Approaches and lessons learned from our experience can be applied to other communities conducing health disparities research.

Evaluation of a Community Health Worker Pilot Intervention to Improve Diabetes Management in Bangladeshi Immigrants with Type 2 Diabetes in New York City

Purpose The purpose of this study is to explore the impact and feasibility of a pilot Community Health Worker (CHW) intervention to improve diabetes management among Bangladeshi-American individuals with type 2 diabetes living in New York City. Methods Participants were recruited at clinic- and community-based venues. The intervention consisted of 6 monthly, CHW-facilitated group sessions on topics related to management of diabetes. Surveys were collected at baseline and follow-up time points. Study outcomes included clinical, behavioral, and satisfaction measures for participants, as well as qualitative measures from CHWs. Results Improvements were seen in diabetes knowledge, exercise and diet to control diabetes, frequency of checking feet, medication compliance, and self-efficacy of health and physical activity from baseline to 12 months. Additionally, there were decreases in A1C, weight, and body mass index. Program evaluation revealed a high acceptability of the intervention, and qualitative findings indicated that CHWs helped overcome barriers and facilitated program outcomes through communal concordance, trust, and leadership. Conclusions The intervention demonstrated high acceptability and suggested efficacy in improving diabetes management outcomes among Bangladeshi immigrants in an urban setting. The US Bangladeshi population will continue to increase, and given the high rates of diabetes, as well as linguistic and economic barriers faced by this community, effective and culturally tailored health interventions are needed to overcome barriers and provide support for diabetes management.

Birth outcomes associated with receipt of group prenatal care among low-income Hispanic women.

INTRODUCTION Although Hispanic women in the United States have preterm birth and low-birth-weight rates comparable to non-Hispanic white women, their rates fall short of 2010 Healthy People goals, with variability found across states. This study examined the effectiveness of the CenteringPregnancy group prenatal care model in reducing preterm birth and low-birth-weight rates for Hispanic women. METHODS Pregnant Hispanic women at less than or equal to 20 weeks, gestation initiating prenatal care between January 2008 to July 2009 at 2 Palm Beach County, Florida, public health clinics selected either group or traditional prenatal care. Data on neonatal birth weight and gestational age were obtained through abstraction of Palm Beach County Health Department medical records. Records were abstracted for 97% of CenteringPregnancy (n = 150) and 94% of traditional care (n = 66) participants. RESULTS A statistically significant difference was found in the percentage of women giving birth to preterm neonates (5% group prenatal care vs 13% traditional care; P= .04). There were no statistically significant differences in the percentage of women having a low-birth-weight neonate when group and traditional care participants were compared. DISCUSSION The CenteringPregnancy model holds promise for improving the birth outcomes of Hispanic women. Future research should be conducted with larger sample sizes to replicate study findings using experimental designs and incorporating formal cost-effectiveness analyses.

Psychiatric disorder symptoms, substance use, and sexual risk behavior among African-American out of school youth

PURPOSE To examine the association between symptoms of psychiatric disorder (i.e. depression, anxiety, and substance use) and sexual risk behavior in a sample of African-American adolescents and young adults in an employment training program. METHODS Baseline data were used from a pilot study of an intervention to reduce depressive symptoms among youth disconnected from school and the workforce. Participants were recruited from two employment training programs in East and West Baltimore (N=617; age 16-23 years). Data were collected through audio computer-assisted self-interview (ACASI). Mental health indicators were measured using the Center for Epidemiological Studies Depression Scale and Beck Anxiety Inventory. Multivariate logistic regression was used to determine the odds of sexual risk behavior for each mental health condition and combinations of conditions. RESULTS Lack of condom use at last sex was significantly associated with elevated anxiety symptoms. Number of sexual partners was associated with elevated depression symptoms and substance use. Early sexual debut was associated with substance use in the past 30 days. Also, there were differences in the likelihood of engaging in sexual risk behavior comparing groups with different combinations of mental health problems to those with no symptoms of disorder or substance use. CONCLUSIONS The results demonstrate the need for HIV prevention programs that target out-of-school youth, as they are likely to engage in risky sexual behavior. Our findings highlight the need to develop behavioral interventions that address disorder symptoms, substance use, and risky sexual behavior among youth in employment training programs.

Coping, Stress, and Social Support Associations With Internalizing and Externalizing Behavior Among Urban Adolescents and Young Adults: Revelations From a Cluster Analysis

PURPOSE To use cluster analysis to explore how coping, stress, and social support align and intersect with each other and relate to internalizing and externalizing behavior among urban adolescents and young adults disconnected from school and work. METHODS Baseline audio computer assisted self-interview (ACASI) data from a study of 683 urban, low-income, African-American 16-24-year-old youth (mean age = 18.7; SD = 1.8) participating in an employment training program was cluster analyzed. This method reveals how well youth group together based on coping strategies, stress exposure, and social support. RESULTS Using four coping, two support, and two stress subscales, a three-cluster solution best fit the data. One cluster, representing 65% of the sample, was characterized by moderate coping, high support, and low stress. These youth also reported lower weapon carrying compared to youth in the remaining two clusters. Another cluster, representing 17% of the sample, was defined by high coping, moderate support, and high stress. Youth in this cluster reported the highest levels of depressive symptoms and high levels of suicidal ideation as well as high levels of perpetrating intimate partner violence compared to other youth. The final cluster, also representing 17% of the sample, was marked by low coping, low support, and low stress. These youth also reported high levels of suicidal ideation. CONCLUSIONS Given the varying profiles of stress, support, and coping reported by urban adolescents and young adults, future research and policy should further explore targeted and tailored intervention approaches for these youth.

Improved adequacy of prenatal care and healthcare utilization among low-income latinas receiving group prenatal care

BACKGROUND This study aimed to examine the effectiveness of the CenteringPregnancy group prenatal care model in improving maternal and child health outcomes, satisfaction with prenatal care, and engagement in prenatal care. METHODS Pregnant Hispanic women ≤20 weeks gestation initiating prenatal care at two Palm Beach County, Florida, public health clinics selected CenteringPregnancy or traditional prenatal care. Data on postpartum visit compliance, establishment of a medical home, child emergency room visits, satisfaction with prenatal care, and engagement in prenatal care were obtained through surveys conducted 3 months post-delivery (n=176; 129 CenteringPregnancy, 47 traditional). Data on prenatal care visits were obtained through abstraction of Palm Beach County Health Department medical records (n=214; 144 CenteringPregnancy, 70 traditional). RESULTS Statistically significant differences were found in satisfaction with prenatal care (84.3 Centering vs. 64.9 traditional, p<.001) and engagement in (39.7 vs. 28.1, p<.001). Centering participants had higher expected prenatal care ratios than traditional care participants (101.9 vs. 83.1, p<.001) and higher percentages receiving adequate prenatal care (90% vs. 63%, p<.001). Centering recipients were more likely to establish a medical home for their child (77% vs. 53%, p<.01) and have a postpartum checkup within six weeks of delivery (99% vs. 94%, p=.04). CONCLUSIONS CenteringPregnancy improves engagement in prenatal care and healthcare utilization outcomes for low-income Latinas. Given disparities that exist between perinatal Latinas and women from other racial/ethnic groups, CenteringPregnancy should be considered as an alternative to traditional 1-on-1 prenatal care for this population.