Deborah Allen, ScD
Boston Public Health Commission
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A bit of context
◦ Why the focus on stress
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Modeling the impact of stress
◦ Diderichsen model
◦ A simplified model (GEfGW)
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Putting the model to work
◦ Programmatic options, downstream and up
◦ Implementation tools
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And beyond
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Long-term dilemma in MCH
◦ Why have past interventions not resolved disparities
in birth outcomes
 We have focused on
 Access to prenatal care
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Financing
Geography and transportation
Awareness
Support
 Health behaviors
 Drugs
 Smoking
 Diet
 Without success at closing the race/ethnicity gaps
<1500 grams
1500-2499
grams
2500+ grams
BOSTON
1.0%
5.4%
93.5%
Asian
n<5
4.7%
94.9%
Black
1.8%
7.5%
90.7%
Latino
1.3%
5.7%
92.9%
White
0.6%
3.8%
95.6%
Data Source: Boston resident live births, Massachusetts Department of Public Health
Data Analysis: Boston Public Health Commission Research and Evaluation Office
Race/Ethnicity
Timing of Birth
<28 Weeks
28-32
33-36
White
15
25
30
Latino
19
21
23
Black
56
47
35
Asian
7
4
6
Infant Deaths (per 1,000 live births)
2008
2009
2010
Boston
7.2
6.5
3.7
Asian
n<5
8.2
n<5
Black
14.6
7.7
7.4
Latino
8.1
8.0
4.7
White
3.4
5.0
1.6
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In US and internationally
In relation to specific chronic conditions
In relation to racial/social disparities in health
generally
As an explanation for persistent disparities in
health outcomes
As a guide to intervention
1)
A focus on early exposure to risk
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2)
3)
And on cumulative risk over the life span
Renewed interest in social determinants of
health
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4)
Or more broadly, risk at periods of high vulnerability
This is not a new idea but it is rediscovered and
reframed periodically
A new emphasis on stress as the link between
social experience and health
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Evidence of the consequences of adverse
birth outcomes
◦ Proximal consequences
◦ Distal consequences: the Barker Hypothesis
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Some exposures are uniquely dangerous at
specific critical periods
◦ Folic acid deficit in first trimester
◦ Alcohol dependency in adolescence
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Concept of “critical periods” has been applied
to impact of insults in utero
◦ Cardiovascular disease
◦ Non-insulin dependent diabetes
◦ Hypertension
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With acknowledgement of later modifying
factors and/or later compounding factors
◦ The case of asthma
 Link to maternal prenatal stress
 Link to postpartum mother and child stress
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Risk accumulates within lifetime of
individual
◦ Long term risk
◦ Synergy across multiple risks
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Evidence suggests risk accumulates
across generations
◦ “Grandmaternal” birth weight as predictor of
infant birth weight
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Adds a dynamic dimension to model
Percent of Births Within Age and
Racial/Ethnic Group
16.0%
12.0%
8.0%
4.0%
0.0%
15-17
18-19
20-24
25-29
30-34
35-39
40+
Asian
14.7%
0.0%
11.9%
5.9%
6.5%
7.4%
5.4%
Black
10.7%
11.2%
13.7%
12.8%
13.8%
14.0%
15.9%
Latino
12.4%
8.0%
7.5%
7.6%
7.4%
8.9%
9.7%
White
5.5%
10.1%
7.7%
6.2%
6.9%
7.5%
11.0%
The causes most often listed for
disparities in adverse outcomes across
group of children
◦ Components of the ACES
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Substance abuse
Family break-up
Parental depression
Child abuse and neglect
Criminal involvement of family member
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Income
Employment
Education
Interaction with criminal justice system
Food: adequate, safe, healthy
Clean air and water
Housing and neighborhood safety
Social support
Access to health care
Transportation
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Discrimination
◦ Both as a cause of the elements listed above
◦ And as a psychosocial experience, with its own
direct consequences for health
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Doleac and Stein, 2010: discrimination in
housing sales
Bertrand and Mullainathan, 2002: discrimination
in employment
◦ Even when applicant documented widely promoted “self
improvement” efforts
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Baker et all, 2006: unequal distribution of fast
food outlets and supermarkets and of healthy
foods within those outlets in St. Louis
Poe-Yamagata and Jones, 2000: discrimination
against youth of color at all stages in criminal
justice process
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According to the WHO, stress may
reflect or be expressed in terms of
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Anxiety
Insecurity
Low self-esteem
Social isolation
Lack of control over work and home life
The WHO perspective: It’s not just about
money, it is also about the mind-body
connection
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Not necessarily defined by where the bottom
and top of the ladder are
But affected by distance from bottom to top
Ever Had Close Family Member or Friend Killed
By Selected Indicators, 2008
BOSTON
48%
Female
Male
51%
44%
Asian
Black
Latino
White
9%
56%
52%
17%
<4 years in US
4+ years in US
Always in US
27%
44%
52%
0%
10%
20%
30%
40%
50%
60%
Percent of Boston Public High School Students
NOTE: Survey question reads, “In your entire lifetime, have any close family members or close friends of yours been killed by
violence, like being shot, stabbed, or beaten to death (do not include those include in war)?”
DATA SOURCE: Boston Youth Survey, 2008; Harvard Youth Violence Prevention Center through a Cooperative agreement
with the Center for Disease Control and Prevention
DATA ANALYSIS: Harvard Youth Violence Prevention Center
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US and international studies link ambient
violence to preterm birth, low birth weight
and infant death
Lauderdale, looking at Arabic-named women
in CA six months after 9/11, found 2-fold
increase in LBW compared with prior year
Increasing evidence that asthma rates
(incidence and exacerbation) link to
community violence
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Our strategies must
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Reduce early adverse exposures
Disrupt accumulation of risk over time
Address social determinants
Eliminate or reduce impact of stressors
Figure
Source: The Lancet 2002; 359:259 (DOI:10.1016/S0140-6736(02)07418-4)
Terms and Conditions
Social determinants/inequality
Social stress
Psychological stress
Physiological stress over time/allostatic load
Adverse health effects/intergenerational effects
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Healthy Start in Housing
Medical-Legal Partnership
CORI reform
Financial literacy
Improved access to benefit programs
◦ One-stop shopping, etc.
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Centering and other group models
Project LAUNCH
Problem Solving Education
Father/partner engagement
Access to stress reduction programs
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Centering
Universal newborn home visiting
Enhanced case management
Defending Childhood Initiative/Trauma
informed care
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Breastfeeding
Improved pregnancy care
◦ Progesterone access
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Improved access to LARCs
Primary care/ob linkage to mental health
Primary Outcome: Maternal Functioning
General health
Depressive
symptoms
Social
Functioning
The 12-Item Short Form Health Survey (SF-12) is a widely used, reliable and valid measure of physical and mental
health.19, 20 21 The mental health component includes domains of vitality, social functioning, role functioning, and
general mental health.
Center for Epidemiological Studies Depression Scale (CES-D) is a 20 item self-report depressive symptom scale
which has been used a diverse populations.22 23 24 Its validity as a measure of depression has been confirmed in
adolescents,25 adults 15, 26, and clinically depressed individuals 27.
Social Adjustment Scale Self-Report (SAS-SR) 28 examines social and role functioning in six areas: work; social
activities; relationships with family; role as spouse, parent; family member. The SAS has high internal consistency
(Cronbach α, r=0.74) and test-retest reliability (r=0.80).
Primary Outcome: Maternal Stress
General Stress
Perceived Stress Scale (PSS) – Stress domains include unpredictability, lack of control, burden overload, and stressful
circumstances. Reliability studies show Cronbach’s α of 0.78 -0.86 29-31.
Parenting
Stress
Parenting Stress – Short Form (PSI) – The PSI assesses a wide range of parenting behaviors, including attachment to
child, social isolation, competence, relationship with partner, and parental health 32, 33. Cronbach’s α for the parent
domain is 0.93 and the test-retest coefficient is 0.96 34.
Primary Outcome: Maternal Health Behaviors Associated with Healthy Birth Outcomes**
Substance Use
Birth Spacing
Health risk/
promotion
behaviors
Follow-up for
pregnancy risks
Pregnancy Risk Assessment Monitoring System (PRAMS) was designed to collect state population-based data on
maternal attitudes and experiences before, during, and after pregnancy. We will use phase 6 questions from the core
and standard questionnaires that focus on alcohol and tobacco use 35.
Pregnancy Risk Assessment Monitoring System (PRAMS) We will use phase 6 questions that focus on pregnancy
intention, contraceptive use, and length of time between pregnancies 35 .
Self-report – daily vitamin supplement, sexual risk practices, exercise
Chart review – examples: OGTT for women with gestational diabetes; follow-up for BP monitoring for women with
hypertension; engagement in mental health services
Secondary Outcome: Parenting Practices and Family Cohesiveness
Family
Routines
The Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) was designed to provide policy makers and
researchers with detailed information about children's early life experiences. We will use questions from 9 month, 2
year, and preschool interviews that focus on family routines 36
Secondary Outcome Child Health Services Utilization**
Child health
service
utilization
Proportion of well child visits scheduled and attended – child’s medical record
Emergency room visit – self report
Immunization delays – child’s medical record
Potential Mediating Variables
Problem
Solving Skills
Coping
Orientation
Behavioral
Activation
Mastery
Hope
Social Problem Solving Inventory -Revised (SPSI-R) is 25 item instrument that measures problem
orientation and problem-solving skills. It was validated with a diverse community sample. Subscale
internal consistency scores range from .76-.92; test-retest reliability ranges from 0.72-0.88 37, 38.
Brief Coping Orientation to Problems (Brief COPE) is a 28 item scale that measures 14 different
adaptive and problematic coping reactions. Subscale Cronbach alpha scores range from .50-.9039.
Behavioral Activation for Depression Scale (BADS) is a 25 item scale measuring avoidance
behaviors and engagement in pleasant activities that affect depressive symptoms. Internal
consistency and test-retest reliability were acceptable (α=.87, r=.74, respectively).40
Pearlin Mastery Scale, a widely used measure of perception of control consisting of 7 items. Internal
consistency scores range from 0 .76-0.77 41, 42.
The Adult Hope Scale is a 12 item scale that measures agency and cognitive appraisals. Cronbach's
alphas ranged from .74 to .84. The test-retest correlations were .76-.82 over a 10 week interval 43.
Potential confounding and effect modifying variables
Participant
characteristics
Housing history
Trauma history
and symptoms
Social Support
Self-report of age, race, ethnicity, nativity, family composition, health history
We use housing history questions from the U.S. Department of Housing and Urban Development
study of the impact of housing on 3,000 homeless families across 12 communities. 44 The questions
assess present housing, history of homelessness, and housing barriers.
Stressful Life Events Questionnaire is standardized trauma history screening measure with good
test-retest reliability (kappa=0.73) and adequate convergent validity (kappa=0.64). 45
Modified PTSD Symptom Scale (MPSS) is a psychometrically valid 17-item scale that assesses
trauma experience and posttraumatic stress symptoms. DSM-IV criteria can be applied to create a
proxy variable for PTSD diagnostic status. 46
Medical Outcomes Survey Social Support (MOS-SS) comprises 4 functional support scales
(emotional/informational, tangible, affectionate, and positive interaction) and an overall social
support index. Subscales are reliable (α’s > 0.91).17
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What tools are being used to screen women before and after pregnancy? What is being used in Boston? Available
tools other than Edinburgh?
◦ CES-D, BEC
What best practices are provided to women at risk of depression to prevent poor birth outcomes
◦ PSE, Centering, father involvement, Wrap around in early childhood mental health, trauma informed care
How do you reach the very hard-to-reach mothers?
◦ Newborn home visiting, Healthy Start in Housing, Partnership with Health Care for the Homeless
Does BPHC have an evidenced based curriculum that is being used?
◦ PSE, Centering, Fatherhood
Is BPHC holding any group sessions for maternal stress and how are they dealing (if at all) with the father
involvement piece?
◦ Centering, Women’s Circles, Healthy Start in Housing
Group-based and population/community-based strategies to reduce maternal stress?
◦ Centering. wide promotion and support for trauma informed care, summer enrichment
Are there strategies, such as social marketing, being used to increase social capital in order to mitigate the
impact of stress?
◦ Social marketing around early childhood mental health, ECMH Parent Council, Healthy Start Consumer
Work Group, Violence Prevention and Intervention, Centering
Who provides the services, professional/ paraprofessional, nurse, mental health counselor?
◦ All of the above
Are there interventions that can address cumulative stress vs. pregnancy stress?
◦ Progesterone promotion, HSiH, Early Childhood Mental Health, LARC Loan Pilot Project
◦ Weak on preconceptional care
How to measure depression as related to birth outcomes?
◦ Screening in pediatrics, newborn home visiting
Have you collected data on the sources of stress, including ACEs, or symptoms only?
◦ Healthy Start in Housing, Women’s Health Questionnaire, Early Childhood Mental Health
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Life course is teaching us humility
◦ It teaches us to identify the stress in women’s lives
and to respect their struggles
◦ And acknowledges that there are major social
forces at work: health education is not enough;
individual resilience has its limits
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But it also opens the door
◦ To community organizing approaches
◦ To new partnerships with the women they serve
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And to a renewed commitment to equality
W.E.B. Dubois, The Souls of Black Folk