Mental health literacy and postpartum depression: a qualitative description of views of lower income women.

The purpose of this study is to understand mental health literacy (MHL) (Jorm, 2000) in lower income women postpartum and share participant experiences of recognizing and seeking help for depressive symptoms. Focus group textual data were received from 25 participants who completed a weight and psychosocial health longitudinal study. Iterative content data analysis using Jorm's framework provided thematic understandings descriptive of MHL. Women recognized behavioral changes indicating mental distress, but fears prevented them from seeking help, and some resorted to risky behaviors. This framework could guide providers to identify women who may benefit from early intervention for postpartum depressive symptoms.

Cumulative poor psychosocial and behavioral health among low-income women at 6 weeks postpartum.

BACKGROUND: During the postpartum period, women may experience unfavorable psychosocial and behavioral health in multiple domains with adverse effects on parenting and maternal and infant health. Yet, little is known about the accumulation of poor health across the domains of depressive symptoms; body image; diet and physical activity; substance use including smoking and alcohol; and general self-care at 6 weeks postpartum, the usual end of maternity care. OBJECTIVES: The aims of this study were to evaluate relationships among the domains comprising psychosocial and behavioral health and to examine the distribution and risk factors associated with cumulative poor psychosocial and behavioral health at 6 weeks postpartum. METHODS: This study was a secondary analysis of cumulative poor health assessed by self-report scales for depressive symptoms, body image dissatisfaction, diet and exercise, substance use, and general self-care among 419 low-income White, African American, and Hispanic women at 6 weeks postpartum. Multivariable Poisson and logistic regression were used in key analyses. RESULTS: The correlation among psychosocial and behavioral domains had a range of r = .50-.00. In this sample of women, 45% had two or more domains in which they had poor health. The model testing risk factors for cumulative poor health was significant (likelihood ratio chi-square = 39.26, df = 11, p < 0.05), with two significant factors: not exclusively breastfeeding (odds ratio [OR] = 1.459, 95% confidence interval [CI] [1.119, 1.901]) and Hispanic ethnicity (OR = 0.707, 95% CI [0.582, 0.858], psuedo-R = .029). Within individual domains, significant risk factors (body mass index, not exclusively breastfeeding, ethnicity, education level, and parity) varied by domain. DISCUSSION: Many low-income women postpartum have poor psychosocial and behavioral health in multiple domains, which constitute areas for health promotion and early disease prevention.

Ethnic-specific weight-loss interventions for low-income postpartum women: findings and lessons.

Promoting weight loss among overweight low-income postpartum women has proven difficult. The study's aims were to pilot-test ethnic-specific weight-loss interventions using randomized control-group designs for White/Anglo (n = 23), African American (n = 25), and Hispanic low-income postpartum women (n = 23) and draw lessons from psychosocial data and follow-up interviews. Interventions lasting 13 weeks were offered in group settings in the community. Similar to other randomized trials with low-income mothers, weight changes between intervention and control groups were nonsignificant in each ethnic group; however, changes correlated significantly with self-efficacy (Spearman r = .50) for White/Anglo women and self-efficacy (Spearman r = -.48) and perceived stress (Spearman r = .48) for African American women. In follow-up interviews, women felt interventions gave a good foundation for weight loss, but program and situational factors affected participation and weight loss. Control groups (mailed interventions later) were generally more pleased with their assignment than intervention groups.

Self-efficacy scale for weight loss among multi-ethnic women of lower income: a psychometric evaluation.

OBJECTIVE: This study examined test-retest reliability, internal consistency, and construct and predictive validity of the Physical Activity and Nutrition Self-Efficacy (PANSE) scale, an 11-item instrument to assess weight-loss self-efficacy among postpartum women of lower income. METHODS: Seventy-one women completed the PANSE scale and psychosocial measures at baseline and at 7 and 13 weeks of a pilot study of weight loss. RESULTS: Test-retest reliability of PANSE scores was r = 0.55 (P < .01). Cronbach α was r = 0.89. Construct validity was supported by correlations with less-healthful behaviors (r = -0.33, P = .005), perceived stress (r = -0.24, P = .04), and decisional balance (r = 0.25, P = .03). PANSE change scores correlated with intervention group weight changes (r = -0.54, P < .01), although baseline scores did not. One factor emerged (loadings .80 to .57). CONCLUSIONS AND IMPLICATIONS: The PANSE scale demonstrated adequate reliability, internal consistency, construct validity, and moderate predictive validity. Replication is needed to confirm study findings.

The distribution of weight-related risks among low-income women during the first postpartum year.

OBJECTIVE: To describe the distribution of weight-related risks (weight retention and overweight/obese status) during the first postpartum year and determine if risk distributions differ by race/ethnicity, time, age, or parity. DESIGN: Secondary analysis of a longitudinal data set from 1- to 3-days to 12-months postpartum. SETTING: Initial recruitment was from a community hospital. PARTICIPANTS: Two hundred and forty-seven (White, African American, or Hispanic) low-income women. RESULTS: At 1- to 3-days postpartum weight-related risks were distributed as follows: 6.1% no risk, 17.0% significant postpartum weight retention, 12.1% overweight/obese, and 64.8% both weight-related risks; at 12 months, the distribution was 32.4%, 8.9%, 16.6%, and 42.1%, respectively. Distributions differed by race/ethnicity at 6-months (χ² =16.1, p=.013) and 12-months postpartum (χ² =19.7, p=.003). Having both weight-related risks (vs. not) at 12 months was 3.1 (odds ratio [OR]) times more likely (95% confidence interval [CI], 1.6, 6.2) for African American and 2.4 (OR) times more likely (95% CI[1.3, 4.6]) for Hispanic than White women. Having two risks decreased significantly only between 1 to 3 days and 6 weeks (p = .000). Maternal parity, but not age, was associated with weight-related risk distributions on four of five time points. CONCLUSION: Despite changes in the weight-related risk distributions from 1- to 3-days to 6-weeks postpartum, the proportion of African American and Hispanic women with weight-related risk (especially having two weight-related risks) remains high at 12-months postpartum.

Developing health promotion interventions: a Multisource Method applied to weight loss among low-income postpartum women.

Developing focused and relevant health promotion interventions is critical for behavioral change in a low-resource or special population. Evidence-based interventions, however, may not match the specific population or health concern of interest. This article describes the Multisource Method (MSM), which, in combination with a workshop format, may be used by health professionals and researchers in health promotion program development. The MSM draws on positive deviance practices and processes, focus groups, community advisors, behavioral change theory, and evidence-based strategies. Use of the MSM is illustrated in the development of ethnic-specific weight loss interventions for low-income postpartum women. The MSM may be useful in designing future health programs designed for other special populations for whom existing interventions are unavailable or lack relevance.

Altered perceptions of personal control about retained weight and depressive symptoms in low-income postpartum women.

Postpartum weight retention and depressive symptoms have a high prevalence among low income women. This qualitative study describes low-income women's experiences of weight changes and depressive symptoms during the late postpartum period. Women (n = 25) who were either overweight or had depressive symptoms, or both, at 12 months postpartum participated in an ethnically-congruent focus group. Women's experiences indicated altered personal control related to retained postpartum weight and depressive feelings. Retained weight negatively affected self-esteem and family functioning. Depression left women feeling isolated yet reluctant to seek help. These findings could provide the basis for health promotion interventions relevant to this population.

Applying the concept of positive deviance to public health data: a tool for reducing health disparities.

The concept of positive deviance (PD), which highlights uncommon practices that reduce risk in low-resource communities, has been effective in community mobilization and programming to improve health outcomes. We present a protocol for extending the concept to analysis of existing public health data. The protocol includes assessing whether PD fits the situation, identifying positive deviants, and identifying behaviors associated with positive deviants' healthy outcomes. Analyzing existing datasets from a PD perspective may aid public health nurses in efforts to reduce health disparities. The effectiveness of our protocol will be clarified in future research.

Measuring dietary intake in nursing research.

Accurately assessing dietary intake is an essential component of international health research to identify nutritional deviations that may place people at risk for developing chronic diseases. Accurate assessment may be hampered by failure to address known measurement problems with traditional dietary assessment tools. This article describes the application and advantages and disadvantages of 5 frequently used dietary assessment methods, discusses the management of measurement error common to each, and recommends use of these methods in community-based health research. Using complementary assessment methods at multiple measurement points enhances the reliability of the findings. Assessing overall dietary quality is consistent with a holistic approach to interventions designed to improve health and is a valuable methodology for nutritional research. Using innovative approaches may more accurately identify dietary patterns that contribute to disease development. Although complex, examining nutritional intake in health research is essential to determining an individual's disease risk status and response to treatment.

The structure of thriving/distress among low-income women at 3 months after giving birth.

This article explores the dimensionality of thriving among low-income Anglo, African American, and Hispanic women using factor analysis of psychosocial, behavioral, and weight measures at 3 months postpartum. Three factors were extracted for each ethnic group. The first and most robust factor was psychosocial distress, which encompassed stress, depressive symptoms, (low) social support, (unhealthy) lifestyle, and (less favorable) body image. For Anglo and Hispanic women, self-regulation also loaded on the distress factor. The findings suggest that interventions to ameliorate psychosocial distress among low-income women, regardless of ethnicity, may need to consider a comprehensive range of intervention content.

Trajectory of weight changes in the first 6 weeks postpartum.

OBJECTIVE: To determine the trajectory of postpartum weight changes and to examine associations between weight change in the first 6 weeks postpartum and demographic, clinical, psychosocial, and behavioral variables. DESIGN: Prospective, longitudinal design. SETTING: Community hospital and university research setting. PARTICIPANTS: 26 low-income women (9 White, 8 Black, and 9 Hispanic) with uncomplicated term pregnancies. MAIN OUTCOME MEASURE: Body mass index measured weekly. RESULTS: Among White women, body mass index decreased significantly for the first 3 weeks of the postpartum period. Black women experienced a significant reduction in body mass index for only the first 2 postpartum weeks. Similarly, the postpartum body mass index decreased for the first 2 weeks for Hispanic women. Prepregnancy body mass index and gestational weight gain each had a significant positive effect on postpartum body mass index. Perception of social support at 4 weeks had a significant positive effect on postpartum body mass index in Black women. CONCLUSIONS: The trajectory of weight change was nonlinear with large initial weight losses during the first 2 to 3 weeks postpartum followed by weight plateaus for the remainder of the first 6 weeks postpartum.

Retention of pregnancy-related weight in the early postpartum period: implications for women's health services.

OBJECTIVE: To examine the proportion of women who reached their prepregnant weight at 6 weeks postpartum and the average amount of weight retained or lost by this time; to determine predictors of early (6 week) postpartum weight retention; and to propose related implications for women's health care and services. DATA SOURCES: The literature review was based on a search of Medline for the years 1986 to 2004 using the keywords postpartum weight with inclusion of additional articles known to the authors that did not appear in the electronic search. STUDY SELECTION: The resulting 83 articles were scrutinized to identify those that reported data on weight retention at 6 weeks postpartum (range, delivery to 3 months) and associated anthropometric, social, obstetric, or behavioral predictors. A total of 12 articles met inclusion criteria for the review. DATA EXTRACTION: Data were extracted related to the proportion of women achieving their postpartum weight at 6 weeks postpartum, the amount of weight retained or lost up to 6 weeks postpartum, and predictors of amount of weight retained or lost. DATA SYNTHESIS: On average, at 6 weeks postpartum, women retain 3 to 7 kg of the weight gained during pregnancy, with at least two thirds exceeding their prepregnant weights. Gestational weight gain is the most significant predictor of weight retention. CONCLUSIONS: Women vulnerable to obesity and weight gain need weight-related health care and improved access to such care to promote weight loss after 6 weeks postpartum.

Physical activity in low-income postpartum women.

PURPOSE: To validate the 7-day physical activity recall (PAR), including alternative PAR scoring algorithms, using pedometer readings with low-income postpartum women, and to describe physical activity patterns of a low-income population of postpartum women. METHODS: Forty-four women (13 African American, 19 Hispanic, and 12 White) from the Austin New Mothers Study (ANMS) were interviewed at 3 months postpartum. Data were scored alternatively according to the Blair (sitting treated as light activity) and Welk (sitting excluded from light activity and treated as rest) algorithms. Step counts based on 3 days of wearing pedometers served as the validation measure. FINDINGS: Using the Welk algorithm, PAR components significantly correlated with step counts were: minutes spent in light activity, total activity (sum of light to very hard activity), and energy expenditure. Minutes spent in sitting were negatively correlated with step counts. No PAR component activities derived with the Blair algorithm were significantly related to step counts. The largest amount of active time was spent in light activity: 384.4 minutes with the Welk algorithm. Mothers averaged fewer than 16 minutes per day in moderate or high intensity activity. Step counts measured by pedometers averaged 6,262 (SD = 2,712) per day. CONCLUSIONS: The findings indicate support for the validity of the PAR as a measure of physical activity with low-income postpartum mothers when scored according to the Welk algorithm. On average, low-income postpartum women in this study did not meet recommendations for amount of moderate or high intensity physical activity.

Do low-income women attain their pre-pregnant weight by the 6th week of postpartum?

OBJECTIVES: To assess the proportion of women attaining pre-pregnant weight, and to ascertain the predictors of amount of retained weight at 6 weeks postpartum, in a tri-ethnic sample of low-income women. DESIGN: Short-term longitudinal design from post-delivery to 6 weeks postpartum. PARTICIPANTS: 419 African-American, Hispanic, and White women receiving perinatal care funded by Medicaid. MAIN OUTCOME VARIABLES: Proportion of women attaining pre-pregnant weight at 6 weeks postpartum; the amount of weight retained at 6 weeks postpartum. RESULTS: Fifteen percent of women attained their pre-pregnant weight at 6 weeks postpartum. In multiple regression analysis, maternal weight gain during pregnancy was the predominant predictor (B=.88, SE=.02, P=.000). Hispanic ethnicity (B=.69, SE=.33, P=.039) and the interaction between maternal weight gain and gestational length (B=-.04, SE=.02, P=.032) made small, independent contributions to amount of retained weight at 6 weeks postpartum. The interaction of ethnicity and maternal age predicted 1.3% of the variance in retained weight, but this was not significant. Health practices were not associated significantly with the amount of weight retained at 6 weeks postpartum. CONCLUSIONS: The majority of women did not return to their pre-pregnant weight by 6 weeks postpartum. The amount of retained weight after delivery is largely influenced by prenatal maternal weight gain.

Weight and behavioral and psychosocial factors among ethnically diverse, low-income women after childbirth: I. Methods and context.

OBJECTIVE: In this paper, we present the background, hypotheses, methods, and descriptive findings from the Austin New Mothers Study, a longitudinal series measuring weight and contextual variables across the first postpartum year. Among the distinguishing features of this study are its tri-ethnic sample of low-income women and its serial measurement of the behavioral and psychosocial context of postpartum weight changes post-delivery and at 6 weeks, and 3, 6, and 12 months postpartum. METHOD: A prospective longitudinal design was used to assess body mass index (BMI), energy intake, fat intake, physical activity, health-related lifestyle, depressive symptoms, body image, and weight-related distress at each observation. SAMPLE: The analytic sample consisted of 382 White, African American, and Hispanic women. FINDINGS: For BMI, effects for ethnicity (p < .001), time (p < .001), and their interaction (p = .005) were significant. All ethnic groups had significant declines in BMI from delivery to 6 weeks postpartum. Thereafter, BMIs of White women declined during the second 6 months, whereas those of Hispanic and African American women either displayed small gains or plateaus between adjacent observations. Time-related effects were significant for behavioral and psychosocial variables except for body image and weight-related distress, whereas effects for ethnicity were significant on fat intake, depressive symptoms, and body image. Despite declines in depressive symptoms, women remained at risk of depression across the first postpartum year. CONCLUSIONS: Low-income ethnic minority women have a higher vulnerability to postpartum weight gains or plateaus. High depressive symptoms occurred in all ethnic groups examined.

Weight and behavioral and psychosocial factors among ethnically diverse, low-income women after childbirth: II. Trends and correlates.

OBJECTIVE: This paper presents a longitudinal analysis of behavioral and psychosocial correlates of weight trends during the first postpartum year. Data are derived from the Austin New Mothers Study (ANMS), a longitudinal study of a low-income, tri-ethnic sample of postpartum women that incorporated serial assessment of weight and behavioral and psychosocial variables. METHOD: Postpartum body mass index (BMI) was measured prospectively (post-delivery, 6 weeks, and 3, 6, and 12 months postpartum). The analytic sample consisted of 382 White, African American, and Hispanic women receiving maternity care funded by Medicaid who had at least three measured postpartum weights. Behavioral and psychosocial variables included energy intakes, fat intakes, physical activity, health related lifestyle, smoking, breastfeeding, contraception, depressive symptoms, emotional eating, body image, and weight-related distress. RESULTS: Using hierarchical linear modeling to incorporate baseline only and time-varying effects, significant associations with postpartum BMI were found for the following variables: ethnicity (p = .001), time of weight measurement (p < .001), the interaction of ethnicity and time (p = .005), pre-pregnant BMI (p < .001), gestational weight gain (p < .001), weight-related distress (p < .001), and energy intakes (p = .005). After adjusting for covariates, ethnic groups displayed differing trends in postpartum BMI resulting in White women having significantly lower BMIs at 12 months postpartum compared to ethnic minority women (p's < .01). CONCLUSION: Behavioral and psychosocial variables contribute to a fuller understanding of BMI status of low-income women during the first postpartum year.