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.
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.
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
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
Why do this study?
Depression in perinatal Latinas
Intragroup comparisons
Strength factors
External resources
Acculturation
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
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
Acculturation
Place of birth
Language preference
Exposure to the U.S. in childhood
Allows for intragroup analysis
Sample
Urban northern California setting – family
health community clinics and dualimmersion 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
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
CES-D Scale
0 Rarely/None = less than 1 day
1 Some/a little = 1 to 2 days
 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
2 Occasionally = 3 to 4 days
3 Most/All the time = 5 to 7 days
 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
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
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?”
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
Risk Variables
Alcohol use
Smoking
Caffeine intake
Cocaine, marijuana, crack, speed, and
other street drugs
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
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
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
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
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
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
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
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
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
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
Extrinsic Resource Factors
Support from adults in the household
affected women regardless of partner
status
Limitations
Cross-sectional design restricts
understanding of dynamic nature of
relationships between culture, context,
events and depressive symptoms
Convenience sample not representative
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