Role of Mediators in Reducing Antepartum Depressive Symptoms in Rural Low-Income Women Receiving a Culturally Tailored Cognitive Behavioral Intervention.

Although cognitive behavioral interventions (CBIs) have demonstrated effectiveness for reducing depressive symptoms in the general population, the mechanism for reducing antepartum depressive symptoms (APDS) in rural low-income and minority women is unknown. This study tested the hypothesis that reducing stress and negative thinking, enhancing self-esteem, and increasing social-support will mediate the effect of a CBI on reducing APDS in rural low-income and minority women. Our findings show that CBI may work through reducing stress and negative thinking and enhancing self-esteem, but not social support. The findings also suggest that mental health care providers should emphasize these activities to reduce antepartum depressive symptoms.

Performance of a Culturally Tailored Cognitive-Behavioral Intervention Integrated in a Public Health Setting to Reduce Risk of Antepartum Depression: A Randomized Controlled Trial.

INTRODUCTION: Cognitive-behavioral group interventions have been shown to improve depressive symptoms in adult populations. This article details the feasibility and efficacy of a 6-week, culturally tailored, cognitive-behavioral intervention offered to rural, minority, low-income women at risk for antepartum depression. METHODS: A total of 146 pregnant women were stratified by high risk for antepartum depression (Edinburgh Postnatal Depression Scale [EPDS] score of 10 or higher) or by low-moderate risk (EPDS score of 4-9) and randomized to a cognitive-behavioral intervention or treatment as usual. Differences in mean change of EPDS and Beck Depression Inventory (BDI)-II scores for low-moderate and high-risk women in the cognitive-behavioral intervention and treatment as usual for the full sample were assessed from baseline (T1), posttreatment (T2), and one-month follow-up (T3), and for African American women in the subsample. RESULTS: Both the cognitive-behavioral intervention and treatment-as-usual groups had significant reductions in the EPDS scores from T1 to T2 and T1 to T3. In women at high risk for depression (n = 62), there was no significant treatment effect from T1 to T2 or T3 for the EPDS. However, in low-moderate risk women, there was a significantly greater mean change in the BDI-II scores from significant decrease in the BDI-II scores from T1 to T2 (4.92 vs 0.59, P = .018) and T1 to T3 (5.67 vs 1.51, P = .04). Also, the cognitive-behavioral intervention significantly reduced EPDS scores for African American women at high risk (n = 43) from T1 to T2 (5.59 vs 2.18, P = .02) and from T1 to T3 (6.32 vs 3.14, P = .04). DISCUSSION: A cognitive-behavioral intervention integrated within prenatal clinics is feasible in this sample, although attrition rates were high. Compared to treatment as usual, the cognitive-behavioral intervention reduced depressive symptoms for African American women at high risk for antepartum depression and for the full sample of women at low-moderate risk for antepartum depression. These promising findings need to be replicated in a larger controlled clinical trial that incorporates methods to maintain greater participant engagement.

A mini-midwifery business institute in a midwifery professional roles course: an innovative teaching strategy for successful career planning and business management of practice.

It is essential to include teaching strategies in midwifery education that address career planning and the business aspects of practice. This article presents the Mini-Midwifery Business Institute (M-MBI), an innovative teaching strategy for midwives that can also be applied to other advanced practice professions. The M-MBI can be integrated into a professional roles course. Before and after graduation, midwifery students and other advanced practice professionals can use the information to gain confidence and skills for successful career planning and the business management of practice.

Social support and self-esteem as mediators between stress and antepartum depressive symptoms in rural pregnant women.

The purpose of this secondary analysis was to determine whether satisfaction with social support and self-esteem mediated the relationship between antepartum stress and depressive symptoms in women attending prenatal clinics in a rural Southeastern community (N = 318). Path analysis with linear regression indicated that the relationship between antepartum stress and depressive symptoms was partially mediated by higher levels of the internal resources of satisfaction with social support and self-esteem. Self-esteem had a greater influence on the relationship between antepartum stress and depressive symptoms than did satisfaction with social support. These findings suggest further study to determine whether developing culturally tailored interventions that emphasize stress reduction activities in addition to enhancing self-esteem and increasing satisfaction with social support can decrease the burden of antepartum depressive symptoms in rural low-income women.

A pilot study: the effect of healing touch on anxiety, stress, pain, pain medication usage, and physiological measures in hospitalized sickle cell disease adults experiencing a vaso-occlusive pain episode.

PURPOSE: This pilot study was conducted to determine the effectiveness of Healing Touch on anxiety, stress, pain, pain medication usage, and selected physiological measures of hospitalized adults with sickle cell disease experiencing a vaso-occlusive pain episode. DESIGN: Healing Touch sessions were administered for 30 minutes on four consecutive days, and the self-reported data on anxiety, stress, pain, and the selected physiological data were collected while controlling for music and presence. METHOD: A parallel-group randomized control trial comparing the effects of Healing Touch with Music (HTM) to Attention Control with Music (ACM). FINDINGS: Due to the small sample size, there were no statistically significant changes in any between-group comparisons, except for present pain on Day 4 for the ACM group. For both groups, the within-group comparison showed a nonsignificant reduction in physiological parameters, a statistically significant reduction in anxiety and stress for the ACM group after Day 4, and a statistically significant reduction in stress in the HTM group after Days 2 and 4. The pre- to postintervention reductions in present pain were greater in the HTM group across all 4 days, but the only statistically significant within groups findings were in the HTM group (p < .01) on Day 1. CONCLUSIONS: Further research is needed.

Catching the spirit of cultural care: a midwifery exemplar.

Midwives provide an integral part of health care in underserved, rural areas of the United States. To meet the health care needs of people from diverse cultures, they need to learn culturally competent care. This article describes efforts by a university and its college of nursing to adapt to a changing cultural climate and prepare faculty and students to become culturally competent in practice encounters with diverse populations. Culturally competent care is infused in the midwifery curriculum through self-directed inquiry and discovery approaches. Outcomes of these approaches are evident in the nurse-midwifery program, which can serve as a model for integration of culturally competent care throughout the nursing curriculum.

A pilot study to reduce risk for antepartum depression among women in a public health prenatal clinic.

This pilot study evaluated the feasibility, effectiveness, and helpfulness of Insight-Plus, a brief culturally-tailored cognitive behavioral intervention for African-American and Caucasian rural low-income women at risk for APD [Edinburgh Postnatal Depression Scale (EPDS) > or = 10]. Forty two percent (63/149) of women in this non-randomized study were at risk for APD and 41% (26/63) of women, who met all eligibility criteria, initially agreed to participate. Seventeen participants completed all six intervention sessions. Ninety-four percent (16/17) who completed their one-month post-intervention interviews had an antepartum recovery rate of 81% (13/16, EPDS < or = 10). Participants reported that many aspects of the program were helpful and they continued to use the intervention exercises after the sessions ended.

Translating research to prevent antepartum depression in a local health department prenatal clinic: a model approach.

This article reports how academic clinical researchers collaborated with administrators, nurses, and social workers in a local health department prenatal clinic to create an evidence-based model approach to prevent antepartum depression. The following steps, adapted from Haynes and Haines, guided this model approach: (1) networking to create partnerships for evidence-based practice, (2) generating the evidence, (3) synthesizing the evidence, (4) creating evidence-based clinical guidelines for best practice, (5) implementing guidelines based on the evidence, (6) evaluating and disseminating the plan, (7) shaping healthcare programming and policy, and (8) collaborating to develop further practice-based research in communities. Academic researchers in other health fields can use these steps to implement their findings in a local health department or community health setting. Furthermore, research is needed to determine the most effective screening questions and interventions to prevent antepartum depression, but the approach described here may be a helpful model for initiating screening and interventions for these women.

Racial disparities in biopsychosocial factors and spontaneous preterm birth among rural low-income women.

In this descriptive prospective study, 269 African American, Hispanic, and Caucasian women from rural prenatal clinics were interviewed once between 16 and 28 weeks' gestation. Associations between biopsychosocial risk factors and preterm birth (PTB) were examined. African American women with spontaneous PTB were more likely to be older, and to have higher Bowman Gray Risk Index scores and hypertensive diseases of pregnancy than African American women who did not have a spontaneous PTB. There were significant differences in bacterial vaginosis, hypertensive diseases of pregnancy, smoking, social support from others, and self-esteem among the three racial groups. In the total sample after adjustment for sociodemographic and biopsychosocial factors, women with spontaneous PTB were three times more likely to be African American, to have oligohydramnios, hypertensive diseases of pregnancy, and had higher Bowman Gray Risk Index scores than the total sample of women without spontaneous PTB. Understanding the risks associated with spontaneous PTBs that are unique to African American women and why biopsychosocial risk factors vary by racial/ethnic group may lead to tailored interventions.

Barriers to seeking help and treatment suggestions for prenatal depressive symptoms: focus groups with rural low-income women.

Interviews were conducted with 21 pregnant or recently pregnant African American and Caucasian low-income women living in a rural southeastern community to elicit perceived barriers to seeking help for depressive symptoms in pregnancy and ways to overcome these barriers, as well as intervention suggestions. Participants identified themes regarding barriers to seeking help. These were: (1) lack of trust, (2) judgment/stigma, (3) dissatisfaction with the health care system, and (4) not wanting help. Themes identified regarding overcoming barriers were: (1) facilitating trust and (2) offering support and help. These and other findings point to the importance of integrating women's ideas into culturally sensitive interventions for women with depressive symptoms or depression in pregnancy that can be provided by a psychiatric nurse-practitioner or other mental health provider.

Risks and resources associated with antepartum risk for depression among rural southern women.

BACKGROUND: Seven to 13% of American women who are pregnant suffers from major depression and 11%-50% experience antepartum depressive symptoms. OBJECTIVE: To examine the prevalence of depressive symptoms in pregnancy and examine the biopsychosocial-spiritual risks and resources in low-income women of diverse racial/ethnic groups. METHODS: Prenatal interviews were conducted at 16-28 weeks gestation with 324 pregnant women from rural prenatal clinics in the southeastern United States; 43% were African American, 31% were Caucasian, and 26% were Hispanic. Multivariate logistic regression tested the contributions of psychosocial risks and psychosocial and spiritual resources to risk for depression (Beck Depression Inventory-II scores >or=16) for the aggregate and for each racial-ethnic group. RESULTS: Beck Depression Inventory-II scores indicating risk for depression were found in 33% of the women. There were no significant differences in symptom rates among African Americans, Caucasians, and Hispanics (37%, 25%, and 36%, respectively). African American race, abuse, more stress, less social support, less self-esteem, and less spirituality were associated with risk for depression, controlling for sociodemographic factors. DISCUSSION: A third of this diverse group of rural low-income women were at risk for depression in pregnancy. It is vital to screen for depressive symptoms in pregnancy and to identify psychosocial risks and resources associated with risk for depression in order to develop interventions for pregnant women with depressive symptoms.

The effect of faith or spirituality in pregnancy: a content analysis.

This study used a qualitative descriptive research design to discover the relevance and meaning of spirituality in the lives of 130 urban low-income pregnant women by asking the open-ended question, "How does your faith or spirituality affect your pregnancy if at all?" Forty-seven percent of the women in this study described how spirituality affected their pregnancy positively, 45% described that spirituality did not affect them, and 5.4% were unsure. A content analysis of those who answered positively revealed six themes from the data describing the meaning of faith or spirituality in pregnancy: (a) guidance and support; (b) protection, blessing, or reward; (c) communication with God; (d) strength and confidence; (e) help with difficult moral choices; and (f) a generalized positive effect. These findings point to the importance of attending to spirituality as a resource in pregnancy for those who value it and further exploring the meaning of spirituality in pregnancy.

Reusable learning units: an innovative teaching strategy for online nursing education.

Constructivist and adult learning theory provided the theoretical framework for reusable learning units (RLUs) developed for a Southeastern University's family nurse-practitioner and nurse-midwifery distance educational programs. Reusable learning units are an organized series of learning events that satisfy one or more interrelated learning objectives that cannot be broken down to component parts without losing semantic and pragmatic meaning. This paper describes the conceptual framework, background and history of RLUs, and collaborative efforts for development and implementation.

Psychosocial and spiritual factors associated with smoking and substance use during pregnancy in African American and White low-income women.

OBJECTIVE: To determine the associations between sociodemographic, psychosocial, and spiritual factors to health risk behaviors during pregnancy in African American and White low-income women. DESIGN: Descriptive, using prenatal interviews and medical record review as data sources. SETTING: An urban prenatal clinic in the Midwestern United States. PARTICIPANTS: One hundred thirty ethnically diverse low-income women. MAIN OUTCOME MEASURES: Smoking and substance use in pregnancy. RESULTS: For the total sample, 39% reported smoking and 28% reported substance use in pregnancy. Significant predictors of smoking were White race, less than high school education, abuse, and religiosity. Abuse and depressive symptoms predicted substance use. African American women were significantly less likely to report smoking in pregnancy (28%) than were White women (55%) (p < .05). African American women who smoked during pregnancy were significantly more likely to report lower levels of education (p < .01), less social support from others (p < .01) and total social support (p < .01), higher levels of stress (p < .05), and more frequent substance use (56.5%) than African American women who did not smoke (12%) (p < .001). White women who used substances were significantly more likely to report smoking (p < .01), abuse (p < .05), and a history of delivering a preterm or low-birthweight infant (p < .01) than the White women who did not. CONCLUSION: Integrating social support and stress-relieving activities in smoking cessation interventions, particularly for African American women, may reduce health risk behaviors, eliminate health disparities, and improve maternal and infant quality of life.

Risks and protective factors associated with symptoms of depression in low-income African American and Caucasian women during pregnancy.

This article describes the risks and protective factors for symptoms of depression in pregnancy among low-income African American and Caucasian women. Data were collected from 130 women who were between 16 and 28 weeks' gestation and enrolled in an urban prenatal clinic. The questionnaires used in the face-to-face interviews consisted of sociodemographic items, the Beck Depression Inventory (BDI-II), the Prenatal Psychosocial Profile (PPP), 3 items from the Jarel Spiritual Well-Being Scale, the Spiritual Perspective Scale, and 4 items on health risk behaviors. Twenty-seven percent of the women reported depressive symptoms at levels indicating risk for clinical depression. However, there were no significant differences between African American and Caucasian women. Sociodemographic factors accounted for 13% of the variance (P < .01) in BDI-II scores. Psychosocial and behavioral risk factors accounted for an additional 19% of the BDI-II variance (P < .001), and psychosocial and spiritual resources accounted for 7% of the variance (P < .001), resulting in these variables accounting for 54% of the total variance in BDI-II scores. Higher levels of stress, lower levels of self-esteem and social support, and higher religiosity had a significant relationship with more symptoms of depression. This supports the need to routinely screen for and to assess factors associated with depressive symptoms in pregnant low-income women.

Are you often sad and depressed? Brief measures to identify women at risk for depression in pregnancy.

PURPOSE: The purpose of this study was to test brief depression screening measures as an initial step to identify women at risk for depression in pregnancy. STUDY DESIGN AND METHODS: Psychometric theory and a prospective correlational research design with a convenience sample of 130 low-income women guided this study. Measurements included (a) single-item depression-screening measures, (b) a two-item depression screening measure, (c) the Brief Depression Screen (BDS), and (d) the Beck Depression Inventory-II (BDI-II), a standardized measure of self-reported depression that has been used widely in pregnancy. RESULTS: Depressive symptoms in pregnancy among these low-income women were 27% (35/128) as determined by a score of 16 or greater on the BDI-II. The two-item depression screening measure, "Are you often sad and depressed?" and "Have you had a loss of pleasurable activities?" had a sensitivity of 91% and a specificity of 52%, whereas the BDS measure had sensitivity of 53% and specificity of 80%. CLINICAL IMPLICATIONS: Asking the two-item screening questions could be an essential first step in determining which women should receive further evaluation and interventions aimed at treating depression during pregnancy.

Effects of spirituality and psychosocial well-being on health risk behaviors in Appalachian pregnant women.

OBJECTIVE: To determine the relationships of spirituality and psychosocial well-being to health risk behaviors in pregnant Appalachian women. METHOD: Descriptive study of 120 women between 16 and 28 weeks of pregnancy. The instruments used were the Spiritual Perspective Scale and religiosity items from the Jarel Well-Being Scale. Psychosocial well-being was measured by the Prenatal Psychosocial Profile. Four items measured health risk behaviors. RESULTS: Higher levels of spirituality (spiritual perspective and religiosity) were significantly correlated with greater satisfaction with social support, higher levels of self-esteem, and decreased levels of smoking. Sociodemographic, psychosocial, and spiritual variables explained 25% of the variance in frequency of smoking, and in the logistic regression analysis, psychosocial stress was the only variable that significantly predicted substance use. CONCLUSION: Higher levels of spirituality and lower levels of stress are associated with decreased health risk behaviors among pregnant women from Appalachia. Increasing spiritual resources and decreasing stress during pregnancy offer the potential to improve health promotion efforts in pregnancy with women from Appalachia.

Mary Breckinridge meets Healthy People 2010: a teaching strategy for visioning and building healthy communities.

In both midwifery and nursing education, it is essential to include innovative teaching strategies that address the health of communities. This article presents a creative learning activity for midwifery and/or nursing education that integrates Mary Breckinridge's historical example with today's national goals for building communities. The establishment of the Frontier Nursing Service in 1925 is an excellent example of the Mobilize, Assess, Plan, Implement, and Track (MAP-IT) framework for building health communities. Advanced practice nursing and midwifery students can use this historical template to implement their ideas for building healthy communities today.

Prenatal psychosocial needs: differences between a TennCare group and a privately insured group in Appalachia.

The purpose of this study was to determine the prenatal psychosocial needs of a group of women enrolled in TennCare, a Medicaid managed care program designed to cover all otherwise uninsured people in Tennessee, and compare them with privately insured women. Face-to-face interviews were conducted using standard and reliable questionnaires with a convenience sample of 120 pregnant women between 14 and 44 years of age and 16 to 28 weeks gestation at three prenatal clinics in East Tennessee. Chi-square analysis revealed that the TennCare enrollees in East Tennessee were significantly more likely to report higher psychosocial needs in pregnancy than the privately insured group. Women enrolled in TennCare had a significantly higher incidence of physical abuse, depressive symptoms, and smoking than the privately insured group. Pregnancy provides a window of opportunity for assessing and intervening with vulnerable women enrolled in Medicaid managed care who report psychosocial problems.

Maternal psychosocial risks predict preterm birth in a group of women from Appalachia.

OBJECTIVES: To identify and evaluate which psychosocial criteria are associated with preterm birth in a midwifery model of risk in pregnancy. DESIGN: A quantitative study with a prospective correlational research design. SETTING: Women attending three prenatal clinics in East Tennessee. PARTICIPANTS: 120 pregnant women between 16 and 28 weeks gestation. The majority of the clinics' clients were from rural Appalachia. MEASUREMENTS AND FINDINGS: Multiple logistic regression statistical analysis revealed that women with symptoms of depression, lower levels of self-esteem, or a negative perception of pregnancy had significantly higher odds of delivering a preterm baby. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These findings suggest the importance of screening for psychosocial risk factors in pregnancy. Interventions to address these psychosocial risks could improve maternal psychosocial health, maintain continuity of midwifery care, and reduce the incidence of preterm birth.