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Hadd AR, Shervinskie A, Clark CJ. Financial stress as a mediator of financial position and depressive symptoms among rural Nepali women. Int J Soc Psychiatry 2025:207640251340820. [PMID: 40380863 DOI: 10.1177/00207640251340820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2025]
Abstract
BackgroundAssets, income, socioeconomic status, and other measures of financial position are consistent predictors of depression. Although financial stress has been proposed as a mediator of this relationship, no study has explored this hypothesis using a rigorous longitudinal design or outside of high-income countries.AimsWe address this gap using longitudinal cohort data across four timepoints.MethodThe sample comprised 831 women (M = 35.9 years old) living in Nawalpur, a rural district in the Gandaki province of Nepal; the majority were married (88%) and of Janajati caste/ethnicity (61%). The direct effect of financial position on depressive symptoms and its indirect effect through financial stress were estimated using a cross-lagged panel mediation model (CLPM); we also conducted cross-sectional mediation models - of the sort typically employed in mediation analyses - for comparison and bias estimation.ResultsIn the CLPM, financial stress significantly mediated the financial position-depressive symptom relationship between timepoints one and three, but not between timepoints two and four (likely due to loss of power). After accounting for financial stress as a mediator, the direct effects of financial position on depressive symptoms were not statistically significant. The cross-sectional models overestimated the relationship between financial stress and depressive symptoms; otherwise, results between the CLPM and cross-sectional models were comparable.ConclusionsOur findings suggest that interventions addressing financial stress may improve depressive symptoms. Methodologically, we argue that more researchers should employ longitudinal designs when investigating mediation processes.
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Affiliation(s)
| | - Abbie Shervinskie
- Emory University, Hubert Department of Global Health, Atlanta, GA, USA
| | - Cari Jo Clark
- Emory University, Hubert Department of Global Health, Atlanta, GA, USA
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Vanderkruik R, Freeman MP, Gaw M, Reuman ARL, Verghese M, Louis CC, Jellinek M, Bartels S, Cohen LS. A mixed-methods study protocol: Perinatal depression screening systems and outcomes in obstetrics clinics. PLoS One 2025; 20:e0319181. [PMID: 40117263 PMCID: PMC11927889 DOI: 10.1371/journal.pone.0319181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 01/29/2025] [Indexed: 03/23/2025] Open
Abstract
Perinatal depression (PND) is an underrecognized and underdiagnosed public health issue with long-term adverse impacts on birthing parents and their children. While obstetrics practices are increasingly encouraged to use existing evidence-based screening tools, there is little data describing the extent to which screening practices and subsequent referrals to care are implemented in clinical settings. The Screening and Treatment Enhancement for Perinatal Depression (STEPS for PPD) study aims to characterize PND screening and referral procedures and identify areas for system improvements. We describe a protocol for an observational study, guided by implementation science frameworks, examining the role of embedded perinatal social workers in managing PND across Mass General Brigham system obstetrics clinics. Our mixed-methods approach integrates qualitative and quantitative data from a variety of sources, including electronic health records, patient-reported surveys, and qualitative interviews, to capture complex screening and referral practices across a large academic medical system. We aim to characterize nuances within the screening and referral system and identify barriers and facilitators to care to inform future hybrid-implementation effectiveness research and improve patient outcomes.
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Affiliation(s)
- Rachel Vanderkruik
- Massachusetts General Hospital, Ammon-Pinizzotto Center for Women’s Mental Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Marlene P. Freeman
- Massachusetts General Hospital, Ammon-Pinizzotto Center for Women’s Mental Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Margaret Gaw
- Massachusetts General Hospital, Ammon-Pinizzotto Center for Women’s Mental Health, Boston, Massachusetts, United States of America
| | - Audrey R. L. Reuman
- Massachusetts General Hospital, Ammon-Pinizzotto Center for Women’s Mental Health, Boston, Massachusetts, United States of America
| | - Maya Verghese
- Massachusetts General Hospital, Ammon-Pinizzotto Center for Women’s Mental Health, Boston, Massachusetts, United States of America
| | - Courtney C. Louis
- Massachusetts General Hospital, Ammon-Pinizzotto Center for Women’s Mental Health, Boston, Massachusetts, United States of America
| | - Michael Jellinek
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stephen Bartels
- The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lee S. Cohen
- Massachusetts General Hospital, Ammon-Pinizzotto Center for Women’s Mental Health, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Zahid N, Blebu B, Felder J, McCulloch CE, Chambers BD, Curry VC, Carraway K, León-Martínez D, Coleman-Phox K, Kuppermann M, Karasek D. Economic Insecurities and Mental Health Among Low-Income Pregnant People in the Central Valley Region of California. Womens Health Issues 2025; 35:105-115. [PMID: 39979154 DOI: 10.1016/j.whi.2025.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 01/04/2025] [Accepted: 01/15/2025] [Indexed: 02/22/2025]
Abstract
BACKGROUND The association between economic insecurity and mental health among low-income pregnant people is understudied. We examined the relationship between economic insecurity and perinatal stress, anxiety, and depressive symptoms among a low-income, racially/ethnically diverse study population, and differentiated associations by nativity status. METHODS We used cross-sectional data from the EMBRACE Study that enrolled Medi-Cal (California's Medicaid program) eligible pregnant people in the Central Valley region of California. Economic insecurity was assessed through measures of food insecurity, low financial well-being, inability to pay an emergency expense, inability to pay bills, fear of eviction, and history of homelessness. We examined the association of these measures with perceived stress (Perceived Stress Scale), generalized anxiety symptoms (Generalized Anxiety Disorder-7), and depressive symptoms (Patient Health Questionnaire-9), adjusting for age, relationship status, and education level. We also examined effect measure modification by nativity among the Latinx population. We report the estimated differences and 95% confidence intervals for each exposure and outcome. RESULTS In our sample of 674 participants, we observed associations between economic insecurity and mental health. Among the 24 models, 15 showed medium to large effects (>0.35 standard deviation differences) and only three showed negligible effect sizes. Across all outcomes, we observed a stronger relationship between economic insecurity and mental health for U.S.-born Latinx people compared with their foreign-born (93% Mexico-born) counterparts. CONCLUSION We found low-income pregnant people experience significant economic insecurities that may impact mental health adversely. Programs that increase economic supports during pregnancy may serve as important maternal mental health interventions, especially among racial/ethnic minoritized groups.
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Affiliation(s)
- Neha Zahid
- School of Medicine, University of California, San Francisco, San Francisco, California.
| | - Bridgette Blebu
- Department of Obstetrics and Gynecology, Lundquist Institute for Biomedical Innovation at the Harbor - UCLA Medical Center, University of California, Los Angeles, Los Angeles, California
| | - Jennifer Felder
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California; Osher Center for Integrative Health, University of California, San Francisco, San Francisco, California
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Brittany D Chambers
- Department of Human Ecology, College of Agricultural and Environmental Sciences, University of California, Davis, Davis, California
| | - Venise C Curry
- Central Valley Health Policy Institute, California State University, Fresno, Fresno, California
| | - Kristin Carraway
- Central Valley Health Policy Institute, California State University, Fresno, Fresno, California
| | - Daisy León-Martínez
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California
| | - Kimberly Coleman-Phox
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California; California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
| | - Miriam Kuppermann
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California; California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California
| | - Deborah Karasek
- Department of Obstetrics, Gynecology, & Reproductive Sciences, University of California, San Francisco, San Francisco, California; California Preterm Birth Initiative, University of California, San Francisco, San Francisco, California; School of Public Health, Oregon Health Sciences University - Portland State University, Portland, Oregon
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Molina NC, Zhou AM, Kaliush PR, Maylott SE, Pappal AE, Wright KR, Neff D, Butner JE, Raby KL, Conradt E, Crowell SE. A bioecological longitudinal study of depressive symptoms from pregnancy to 36 months postpartum. J Affect Disord 2024; 365:56-64. [PMID: 39142585 PMCID: PMC11512642 DOI: 10.1016/j.jad.2024.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 08/06/2024] [Accepted: 08/11/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE Depressive symptoms during the perinatal period have broad and enduring health implications for birthing parents and their offspring. Rising prevalence rates of perinatal depression highlight the need for research examining factors influencing depressive symptoms during pregnancy, and trajectories during the early postnatal period. Grounded in bioecological systems theory, this longitudinal multimethod study examined whether prenatal bioecological factors predict depressive symptoms from pregnancy to 36 months postpartum. METHODS Participants were 162 pregnant individuals, oversampled for high emotion dysregulation, who completed a life stress interview and physiological assessment during the 3rd trimester and a self-report measure of depression at five time-points (3rd trimester, within 48 h of birth, 7, 18, and 36 months postpartum). Multilevel models were used to test study aims. RESULTS Participants exhibited the highest levels of depressive symptoms at 3rd trimester, and substantial variability in depressive symptom trajectories over time. Lower resting respiratory sinus arrhythmia (RSA), an index of parasympathetic nervous system functioning, in the 3rd trimester was associated with higher concurrent depressive symptoms. Higher levels of stress related to partner relationships, finances, and health were concurrently associated with more depressive symptoms during pregnancy and decreases in depressive symptoms over time. Specifically, depressive symptoms decreased only for individuals who reported high levels of stress during pregnancy. LIMITATIONS Although grounded in bioecological systems theory, this study did not assess the macrosystem. CONCLUSIONS Results of this study underscore the importance of multilevel predictors of perinatal health and highlights potential targets for preventing depression and promoting well-being during the perinatal transition.
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Affiliation(s)
- Nicolette C Molina
- Department of Psychology, University of Oregon, Eugene, OR, United States of America.
| | - Anna M Zhou
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America
| | - Parisa R Kaliush
- University of North Carolina (UNC), School of Medicine, Chapel Hill, NC, United States of America
| | - Sarah E Maylott
- University of North Carolina (UNC), School of Medicine, Chapel Hill, NC, United States of America
| | - Ashley E Pappal
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America
| | - Kira R Wright
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America
| | - Dylan Neff
- University of Miami, Coral Gables, FL, United States of America
| | - Jonathan E Butner
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America
| | - K Lee Raby
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America
| | - Elisabeth Conradt
- Department of Psychology, University of Utah, Salt Lake City, UT, United States of America; Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, United States of America
| | - Sheila E Crowell
- Department of Psychology, University of Oregon, Eugene, OR, United States of America
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Marçal KE, Barr N. Predicting homelessness: Housing risk insights from latent class analysis. PLoS One 2024; 19:e0306534. [PMID: 38968256 PMCID: PMC11226121 DOI: 10.1371/journal.pone.0306534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 06/19/2024] [Indexed: 07/07/2024] Open
Abstract
Millions of families with children in the U.S. struggle to afford adequate housing. Housing cost burden places families at risk for homelessness, and prevention efforts are hindered by limited understanding of insecure housing experiences at the margins. The present study investigated variation in housing insecurity experiences in a sample of mothers, as well as which risk profiles were most strongly associated with subsequent homelessness. Latent class analysis identified four distinct subgroups of housing insecurity: "Stable," "Unstable," "Rent-Focused," and "Strategic Bill-Paying." Classes differed on whether they made rent or utility payments on time, experienced utility shutoffs, or were evicted. Mothers who missed rent payments were significantly more likely to experience subsequent homelessness, whereas those who prioritized rent were more likely to have their utilities shut off but remain housed. Policy efforts should emphasize increased wages, rent control, changes to zoning laws and tax codes to prioritize affordable housing, and benefits that help mothers maintain their incomes such as comprehensive healthcare, paid maternity leave, and subsidized childcare.
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Affiliation(s)
- Katherine E. Marçal
- School of Social Work, Rutgers University, New Brunswick, NJ, United States of America
| | - Nicholas Barr
- School of Social Work, University of Nevada Las Vegas, Las Vegas, NV, United States of America
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Kabongo WNS, Mbonigaba J. Public health spending in Sub-Saharan Africa: exploring transmission mechanisms using the latent growth curve mediation model. HEALTH ECONOMICS REVIEW 2024; 14:14. [PMID: 38372932 PMCID: PMC10875913 DOI: 10.1186/s13561-023-00472-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 12/05/2023] [Indexed: 02/20/2024]
Abstract
In response to the imperatives of universal health coverage, structural factors that may hinder the effectiveness of increased spending in sub-Saharan Africa (SSA) need attention. This study assessed the mediating role of these factors in domestic general government health expenditure (DGGHE) effects to propose solutions for improving population health outcomes (PHO). The analysis used the Latent Growth Curve Mediation Model (LGCMM) approach within the structural equation model (SEM) framework for panel data from 42 SSA countries from 2015 to 2018. The findings were that malaria and female education formed a channel through which DGGHE imparted its effects on DALY in SSA, and these effects were achieved via the specific path from the DGGHE slope to the DALY slope, via malaria and female education slopes. However, the paper found no evidence of immunization coverage mediating the relationship between DGGHE and DALY in SSA. The paper concludes that structural factors affect the effectiveness of DGGHE on PHO, implying that governments should emphasize existing programs to fight against malaria and increase immunization coverage.
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Affiliation(s)
- Wa Ntita Serge Kabongo
- School of Accounting, Economics and Finance, University of KwaZulu Natal, University Road, Westville Campus, Durban, South Africa
| | - Josue Mbonigaba
- School of Accounting, Economics and Finance, University of KwaZulu Natal, University Road, Westville Campus, Durban, South Africa.
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Zhou F, He S, Shuai J, Deng Z, Wang Q, Yan Y. Social determinants of health and gender differences in depression among adults: A cohort study. Psychiatry Res 2023; 329:115548. [PMID: 37890404 DOI: 10.1016/j.psychres.2023.115548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/08/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023]
Abstract
The role of social determinants of health (SDoH) in gender differences in depression remains unclear among Chinese adults. We aimed to explore the association between SDoH and depression and investigate their role in explaining gender differences in depression. This prospective longitudinal cohort study used four wave surveys (2012, 2016, 2018, and 2020) of the China Family Panel Study (CFPS). Fourteen SDoH variables were assessed, and depression was measured using the 8-item short version of the Center for Epidemiologic Studies Depression Scale. The Cox proportional hazards regression and multiple mediation analysis were performed to estimate the effect sizes. The longitudinal sample included 18,874 participants aged 18-92 years (51.4 % males and 48.6 % females). Women had higher risk of depression than men. Unfavorable SDoH were associated with higher risk of depression. After including multiple SDoH in mediation analysis, multiple SDoH mediated 15.7 % of the total effect of gender on depression. In sum, SDoH significantly influenced depression, and specific factors explained gender differences in depression. Supporting women in education, employment, and community involvement could help reduce gender differences in depression.
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Affiliation(s)
- Feixiang Zhou
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China
| | - Simin He
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China
| | - Jingliang Shuai
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China
| | - Zhihao Deng
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China
| | - Qi Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China
| | - Yan Yan
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan 410078, China.
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Vanderkruik R, Freeman MP, Nonacs R, Jellinek M, Gaw ML, Clifford CA, Bartels S, Cohen LS. To screen or not to screen: Are we asking the right question? In response to considering de-implementation of universal perinatal depression screening. Gen Hosp Psychiatry 2023; 83:81-85. [PMID: 37141774 DOI: 10.1016/j.genhosppsych.2023.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/10/2023] [Accepted: 04/21/2023] [Indexed: 05/06/2023]
Abstract
This Editorial is a response to the Canadian Task Force on Preventive Health Care's recent recommendation "against instrument-based depression screening using a questionnaire with cut-off score to distinguish 'screen positive' and 'screen negative' administered to all individuals during pregnancy and the postpartum period (up to 1 year after childbirth)." While we acknowledge the gaps and limitations in research on perinatal mental health screening, we have concerns regarding the potential impact of a recommendation against screening and for "de-implementation" of existing perinatal depression screening practices, particularly if there is not careful attention to the specificity as well as limitations of the recommendation, or if there are not clear alternative systems put in place to support the detection of perinatal depression. In this manuscript, we highlight some of our key concerns and suggest considerations for perinatal mental health practitioners and researchers.
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Affiliation(s)
- Rachel Vanderkruik
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA.
| | - Marlene P Freeman
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA
| | - Ruta Nonacs
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA
| | | | - Margaret L Gaw
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America
| | - Charlotte A Clifford
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America
| | - Stephen Bartels
- Harvard Medical School, Boston, MA, USA; The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Lee S Cohen
- Massachusetts General Hospital, Ammon Pinizzotto Center for Women's Mental Health, Boston, MA, United States of America; Harvard Medical School, Boston, MA, USA
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