Perceived stress and depressive symptoms during pregnancy and postpartum in Turkish-origin women living in Germany.

OBJECTIVE: People of Turkish origin (also referred to as "with a Turkish migrant background") are one of the largest migrant groups in Germany and show disparities across different stress-related health outcomes. Specifically, women of Turkish origin in Germany have a greater risk for some mental health issues and adverse pregnancy and birth outcomes compared to women without migrant background. We tested differences between women of Turkish origin and women without migrant background in self-reported pregnancy and postpartum stress experiences and depressive symptoms. METHODS: 32 women of Turkish origin (mean age 29.7 years) and 77 women without migrant background (mean age 32 years) participated in a multi-site prospective cohort study with two study visits during pregnancy and one month postpartum. Women provided sociodemographic data and completed the Perceived Stress Scale (PSS) and the Center for Epidemiology - Depression (CESD) scale at each study visit. RESULTS: Using hierarchical linear models, we found that women of Turkish origin (both first and second generation) reported more perceived stress (b = 0.57, CI: 0.29-0.84, p < 0.001) and depressive symptoms (b = 0.32, CI = 0.14-0.49, p < 0.001) compared to women without migrant background across gestation. A linear regression analysis showed that there was also a significant difference in depressive symptoms at one month postpartum (b = 0.35, CI = 0.03-0.66, p < 0.05). CONCLUSION: Tailored psychosocial interventions are needed to address mental health needs of pregnant Turkish origin women and to intervene on the possible transmission of stress-related health disadvantages to their offspring.

Disentangling language-related item biases in stress research with people of Turkish origin in Germany: An application of the CCT procedure.

Psychological stress experiences play a major role in the development of ethnic health disparities. Investigating such relationships often requires the use of questionnaires in different languages, however, this involves the risk of biased measurements. Such biases may be even more likely to occur the closer the construct being measured is to cultural experiences. We adapted the culture, comprehension, and translation bias (CCT) procedure (Bader et al., 2021) to test three language-related item biases in the measurement of stress experience among people of Turkish origin in Germany (i.e., language choice, comprehension, and translation bias) in the Perceived Stress Scale (PSS) and the Multidimensional Acculturative Stress Inventory (MASI). One thousand three hundred four adult persons of Turkish origin living in Germany participated in an online survey with a quasi-experimental design: participants either chose the German version, were assigned the German version, or were assigned the Turkish version of the study questionnaire. Participants completed the 10-item PSS, 25-item MASI, and other measures, and provided sociodemographic data. The adapted CCT procedure revealed none of the language-related biases for the PSS, whereas for the MASI a language choice bias could be demonstrated for one item, a comprehension bias for one item, and a translation bias for five items. The results suggest that language-related item biases are trait-specific and that the CCT procedure is suitable for testing other item biases beyond those tested by Bader et al. Testing such item biases may improve the study of stress experiences in the context of ethnic health disparities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Role of anti-Asian racism for subjective well-being among people of Asian origin in Germany.

OBJECTIVES: People of Asian origin in Germany are affected by racial-ethnic discrimination, which became even more evident in the context of surging anti-Asian racism (AAR) during the COVID-19 pandemic. Experiences of discrimination can pose a threat to mental health. This study tested the role of discrimination experiences for subjective well-being in a sample of Asian origin people in Germany. METHOD: A total of 671 participants (76.5% women) who self-identified as being of Asian origin participated in an online survey in December 2020. Participants completed several measures of racial-ethnic discrimination experiences, some of which were related to the pandemic (e.g., experienced microaggressions and perceived change in discrimination experiences during the pandemic), as well as indicators of subjective well-being (positive and negative affect, life satisfaction, and subjective health status). RESULTS: In structural equation models, discrimination experiences were associated with lower subjective well-being (b = -.36, SE = .16, p < .05). A follow-up analysis suggested that this relationship was evident for discrimination measures that had a reference to the pandemic as well as measures without this reference. CONCLUSIONS: The range of different discrimination experiences among people of Asian origin in Germany is characterized by discrimination in the context of the pandemic and also beyond, and these may have a significant negative impact on the mental health of those affected. The findings of this study have practical implications both for reducing anti-Asian stigmas in society and in the context of psychological counseling of affected individuals, which should target the maintenance or improvement of subjective well-being. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Diurnal cortisol variation during pregnancy in Turkish origin and non-migrant women in a German birth cohort study.

BACKGROUND: Immigrants from Turkey experience health disadvantages relative to non-immigrant populations in Germany that are manifest from the earliest stages of the lifespan onwards and are perpetuated across generations. Chronic stress and perturbations of stress-responsive physiological systems, including the hypothalamus-pituitary-adrenal (HPA)-axis, are believed to in part mediate this relationship. Cortisol plays an important role in the association between maternal stress during pregnancy and many pregnancy-, birth- and offspring-related outcomes. We therefore examined whether maternal migrant background is associated with diurnal cortisol variation during pregnancy. METHODS: 109 pregnant women (incl. n = 32 Turkish origin women) that participated in a multi-site prospective cohort study in Germany collected saliva samples across the day on two consecutive days around 24 and 32 weeks gestation. Hierarchical linear models were applied to quantify associations between migrant background and diurnal cortisol variation across pregnancy. RESULTS: Women of Turkish origin exhibited a significantly lower cortisol awakening response (CAR) and a flatter diurnal cortisol slope (DCS) compared to non-migrant women after adjusting for household income. These relationships between migrant status and diurnal cortisol variation were mainly driven by 2nd generation migrants. DISCUSSION: A potential HPA axis dysregulation of Turkish-origin pregnant women may contribute to the intergenerational transmission of health disadvantages in this group.

Exposure to childhood maltreatment and systemic inflammation across pregnancy: The moderating role of depressive symptomatology.

BACKGROUND: Childhood maltreatment (CM) has long-term consequences for dysregulation of the immune system which is particularly pronounced when mental and physical health sequelae have manifested. Higher proinflammatory state has been shown in non-pregnant state in association with CM as well as with depression, one of the most frequent and pernicious psychiatric sequelae of CM. During pregnancy, however, this association is less clear. Given the important role of maternal inflammatory state during pregnancy for fetal, pregnancy, and birth outcomes, we sought to examine the association between CM and proinflammatory state during pregnancy considering the moderating role of maternal depressive symptoms characterized serially across pregnancy. METHODS: A prospective, longitudinal study of 180 healthy pregnant women was conducted with serial assessments in early (12.98 ± 1.71 weeks gestation), mid (20.53 ± 1.38 weeks gestation) and late (30.42 ± 1.4 weeks gestation) pregnancy. Maternal history of CM was assessed with the Childhood Trauma Questionnaire (CTQ) and the total score was used as an indicator of CM experience. Maternal depressive symptoms were assessed at each pregnancy visit with the Center for Epidemiologic Studies Depression Scale (CES-D). Serum concentrations of tumor necrosis factor (TNF)-α and interleukin (IL)-6 were obtained at each pregnancy visit and combined to a composite maternal proinflammatory score. Linear mixed effects models were employed to assess the association between CTQ score, CES-D score, and proinflammatory score during pregnancy, adjusting for potential confounders. RESULTS: Gestational age was associated with the proinflammatory score (B = 0.02; SE = 0.00; p < .001), indicating an increase in inflammation across gestation. Neither CTQ score nor depressive symptoms were independently associated with the proinflammatory score (ps > 0.28). However, the interaction between CTQ score and depressive symptoms was associated with the proinflammatory score (B = 0.03, SE = 0.01, p < .05), indicating higher inflammation across pregnancy with increasing levels of depressive symptoms during pregnancy in women with higher CTQ scores. Exploratory analyses suggested that this interaction was mainly driven by CTQ subscale scores assessing experiences of abuse rather than neglect. CONCLUSIONS: These findings suggest a moderating role of maternal depressive symptoms during pregnancy on the association of early life stress with inflammation and thus highlight the importance of the timely assessment of both CM exposure and depressive symptoms which might allow for the development of targeted and individualized interventions to impact inflammation during pregnancy and to ameliorate the detrimental long-term effects of CM. The current findings add to a better understanding of the prenatal biological pathways that may underlie intergenerational transmission of maternal CM.

Acculturation and biological stress markers: A systematic review.

BACKGROUND: The association of acculturation with health among immigrant populations is believed to be mediated, in part, by acculturation-related stress and stress biology. OBJECTIVES: To review and qualitatively synthesize empirical findings on the relationship of acculturation with stress-related inflammatory and endocrine biomarkers and composite allostatic load (AL) scores. METHODS: A literature search was performed in the PubMed and PsycInfo databases. Article titles, abstracts or full-texts were screened and checked for match with the search criteria. Studies were eligible if they empirically tested the relationship between acculturation and inflammatory/endocrine stress biomarkers or composite AL scores, and were published in the English language. RESULTS: Among the 41 articles identified as relevant and included in this review, the majority were published after 2010, included adult Hispanic U.S.-based populations, used cross-sectional study designs, operationalized acculturation as a unidimensional construct, and varied considerably in the selection of covariates in the analyses. Acculturation was significantly associated with stress biomarkers in 29 studies, but the direction of effects varied across studies. Specifically, acculturation, operationalized as a higher orientation towards the host culture, was associated with inflammatory biomarkers in 10 of 14 studies, with endocrine stress biomarkers in 12 of 20 studies, and with composite AL scores in 7 of 8 studies. Overall, language-based proxy measures of acculturation were related to higher levels of stress-related inflammatory and endocrine biomarkers and to lower levels of AL scores, whereas nativity-, generation status- and length of stay-based proxy measures of acculturation were related to higher levels of inflammatory biomarkers and AL score. DISCUSSION: The majority of studies reported associations between measures of acculturation and stress biomarkers, however the directions of effects varied across studies. We suggest this heterogeneity may, in part, be a function of limitations imposed by cross-sectional research designs and unidimensional measures of acculturation measures, and we highlight the need for longitudinal studies and use of multidimensional measures of acculturation to better uncover the biobehavioral mechanisms and pathways linking acculturation with health outcomes.

Association of maternal migrant background with inflammation during pregnancy - Results of a birth cohort study in Germany.

BACKGROUND: Health disparities in children of immigrants are prevalent from birth and are hypothesized to - in part - emerge as a biological consequence of migration's unfavorable social and psychological sequelae. The aim of this study was to examine whether maternal migrant background is associated with inflammation during pregnancy - a key pathway by which maternal states and conditions during pregnancy may influence fetal development and subsequent pregnancy, birth, and child developmental and health outcomes. MATERIAL AND METHODS: Data was available from 126 pregnant women who participated in a population based multi-site prospective birth cohort study in Bielefeld and Berlin, Germany. The study included two study visits in mid- and late pregnancy. At each visit, a composite maternal pro-inflammatory score was derived from circulating levels of plasma inflammatory markers (IL-6, CRP). Migrant background was defined by country of origin of participants and their parents' (Turkey or other) and generation status (1st or 2nd generation). We applied hierarchical linear models (HLM) in order to quantify the relationship between different migrant background variables and inflammation during pregnancy after adjustment for potential confounders (including socioeconomic status). RESULTS: Migrant background was significantly associated with inflammation during pregnancy. When compared to women without migrant background, levels of inflammation were increased in 1) pregnant women with migrant background in general (B = 0.35, SE = 0.12, p < .01); 2) 1st (B = 0.28, SE = 0.15, p < .10) and 2nd generation (B = 0.40, SE = 0.15, p < .01); 3) women with a Turkish migrant background (B = 0.28, SE = 0.14, p < .10) and women with another migrant background (B = 0.42, SE = 0.15, p < .01); and 4) 2nd generation Turkish origin women (B = 0.38, SE = 0.20, p < .10), 1st generation women with other migrant background (B = 0.44, SE = 0.26, p < .10), and 2nd generation women with other migrant background (B = 0.43, SE = 0.17, p < .05). DISCUSSION: Our findings support a role for maternal inflammation as a pathway of intergenerational transmission of migration-related health inequalities, suggest that the effect seems to persist in 2nd generation immigrants, and highlight the need for future research and targeted interventions in this context.

Maternal subjective social standing is related to inflammation during pregnancy.

BACKGROUND: The association of socioeconomic status (SES) with health and disease risk is well established. Low-grade inflammation represents a key pathway believed to underlie this association. Previous research has suggested that subjective social standing (SSS) is more consistently associated with health outcomes than objective measures of SES such as income and education. Given the importance of maternal inflammatory state in a wide array of pregnancy, birth and fetal/child developmental and health outcomes, we examine here the independent association of maternal SSS relative to objective SES with pro-inflammatory state during pregnancy. METHODS: We conducted a longitudinal study of an ethnically diverse sample of 250 pregnant women with 3 study visits in early, mid and late gestation. We obtained objective measures of SES (income, education), and SSS with reference to the community and to the nation using the MacArthur Scale of Subjective Social Status. At each study visit, a composite maternal pro-inflammatory score was derived from circulating levels of inflammatory markers (IL-6, CRP, TNF-α). RESULTS: In hierarchical linear models, SSS but not objective SES was significantly and negatively associated with maternal inflammatory state. Moreover, the relationship between SSS and inflammatory state remained significant after accounting for objective SES. SSS with reference to the community was a stronger predictor of inflammatory state than SSS with reference to the nation. DISCUSSION: Our finding adds to the scientific literature on SSS and health, highlights the importance of including SSS measures in this context, and supports future research on the relative role and biological pathways by which SSS may impact pregnancy, birth and fetal/child development and health.

Intergenerational transmission of health disparities among Turkish-origin immigrants in Germany: study protocol of a multi-centric cohort study (BaBi-stress and BaBeK study).

BACKGROUND: Immigrants in Germany exhibit higher levels of social disadvantage when compared to the non-immigrated population. Turkish-origin immigrants constitute an important immigrant group in Germany and show disparities in some health domains that are evident from birth onwards. Several studies have shown the mechanisms by which social disadvantage is biologically embedded to affect health over the lifespan. Relatively little, however, is still known about if and how the maternal social situation is transmitted to the next generation. This study therefore aims to analyse the effects of maternal socioeconomic status and migration status on stress-related maternal-placental-fetal (MPF) biological processes during pregnancy on infant birth and health outcomes. METHODS: This longitudinal cohort study of N = 144 child-mother dyads is located at two study sites in Germany and includes pregnant women of Turkish origin living in Germany as well as pregnant German women. During pregnancy, MPF stress biology markers from maternal blood and saliva samples, maternal socio-economic and migration-related information, medical risk variables and psychological well-being are assessed. After birth, infant anthropometric measures and developmental outcomes are assessed. The same measures will be assessed in and compared to Turkish pregnant women based on a collaboration with BABIP study in Istanbul. DISCUSSION: This is the first study on intergenerational transmission of health disparities in Germany with a focus on women of Turkish-origin. The study faces similar risks of bias as other birth cohorts do. The study has implemented various measures, e.g. culturally sensitive recruitment strategies, attempt to recruit and follow-up as many pregnant women as possible independent of their social or cultural background. Nevertheless, the response rate among lower-educated families is lower. The possibility to compare results with a cohort from Turkey is a strength of this study. However, starting at different times and with slightly different recruitment strategies and designs may result in cohort effects and may affect comparability of the sub-cohorts. TRIAL REGISTRATION: N.A. (Observational study, no clinical trial, no interventions on human participants).

The German Version of the Multidimensional Acculturative Stress Inventory (MASI) for Turkish-Origin Immigrants -Measurement Invariance of Filter Questions and Validation.

The Multidimensional Acculturative Stress Inventory (MASI) is an established measure of acculturative stress for people of Mexican origin living in the United States that has been associated with mental health outcomes in this population. We translated the MASI into German and adapted it for use with Turkish-origin immigrants in Germany. The MASI includes filter questions asking if a potentially stressful event had actually occurred before reporting the stress appraisal of these situations. Measurement invariance testing has become a standard practice to evaluate questionnaire translations, however, measurement invariance of filter questions has been scarcely studied. In Study I, we evaluated measurement invariance of the filter questions between a German-based Turkish sample (N = 233) and the Mexican-origin sample from the original study (N = 174) and could show partial strong factorial invariance for three of the four factors. In Study II, a validation study, relations between the German MASI scores and measures of acculturation and stress indicated discriminant validity. This study contributes to research on measurement invariance of filter questions, thereby providing a measure of acculturative stress that can be used in future research to understand the etiology of health disparities in Turkish-origin immigrants in Germany.

Perceived discrimination and risk of preterm birth among Turkish immigrant women in Germany.

BACKGROUND: Health disparities, including adverse birth outcomes, exist between Turkish immigrants and the autochthonous population in Germany. The state of research on the risk of preterm birth (PTB, defined as <37 weeks of gestation), the leading cause of infant mortality and morbidity, among Turkish immigrant women is mixed. Perceived discrimination is discussed in the context of health disparities related to migration. We examined whether PTB risk is also increased in Turkish immigrant women in Germany and whether perceived discrimination due to origin contributes to this risk. METHODS: We selected a sample from the German Socio-Economic Panel (SOEP) study of German autochthonous and Turkish immigrant women who recently gave birth (between 2002 and 2016) (N = 2,525, incl. n = 217 Turkish immigrant women of which n = 111 completed an item on perceived discrimination). The included variables of central interest were immigrant status, perceived discrimination, gestational age, and socioeconomic situation. RESULTS: Logistic regression models indicated that PTB risk was significantly higher for Turkish immigrant women than autochthonous women (OR: 2.75, 95% CI [1.79-4.16]), even when adjusting for socioeconomic status. Within the subsample of Turkish immigrant women, perceived discrimination was related to a significantly higher PTB risk (OR: 4.91, 95% CI [1.76-15.06]). CONCLUSIONS: Our study provides evidence for a higher PTB risk in Turkish immigrant women compared to autochthonous women in Germany. Perceived discrimination may contribute to this higher risk. The findings represent an important first step towards developing targeted interventions to improve pregnancy and birth outcomes in minority groups.

Acculturation and interleukin (IL)-6 concentrations across pregnancy among Mexican-American women.

BACKGROUND: The process of acculturation (post-migration acquisition of host culture and/or loss of heritage culture) likely represents a key mediator of the observed post-migration decline in health that is evident among immigrant populations such as Mexican Americans. The observations that migrant health declines progressively as not only a function of length of stay in the U.S. but also across generations, and that this inter-generational decline in health is evident as early as at the time of birth itself, supports the concept of fetal programming of acculturation's effects. However, the underlying mechanisms remain to be elucidated. Inflammation during pregnancy represents a candidate pathway of particular interest for 2 reasons: it represents a key biological mediator of the psychosocial and/or behavioral sequelae of acculturation on health, and it represents a key pathway by which maternal states and conditions during pregnancy may influence fetal development and subsequent birth and child developmental and health outcomes. Therefore, the aim of this study was to examine the relationship between acculturation and inflammation across pregnancy in a population of Mexican-American women. Specifically, we tested the hypothesis that a higher level of acculturation is associated with higher circulating concentrations across pregnancy of the pro-inflammatory cytokine interleukin-6 (IL-6). METHODS: 75 pregnant first- or second-generation Mexican-American women constituted the study population. Acculturation was quantified using a commonly-used and previously validated measure - the Acculturation Rating Scale for Mexican Americans (ARSMA). Maternal blood samples were collected during early, mid and late pregnancy for analysis of circulating IL-6 concentrations. RESULTS: Hierarchical linear models indicated a significantly and positive main effect of acculturation on IL-6 concentrations across pregnancy after adjusting for key covariates including gestational age(s) at blood sampling, socioeconomic status, pre-pregnancy BMI, and presence of obstetric risk conditions. CONCLUSIONS: Maternal inflammation during pregnancy may represent a biological pathway of interest in the context of the inter-generational effects of acculturation from a mother to her as-yet-unborn child.