A qualitative analysis of adolescent motherhood within the broader family context in Peru

Objective

The purpose of this study was to characterize the impact of adolescent pregnancy on families and describe the needs of adolescent mothers and their infants in order to assess the need for intervention and identify potential intervention targets.

Background

Adolescent mothers and their offspring face an increased risk of mental health problems. Adolescent mothers and their families also face significant resource constraints; 95% live in low- and middle-income countries (LMICs). Cost-effective interventions are needed to improve outcomes for this vulnerable group.

Method

This qualitative study conducted in Lima, Peru, consisted of four clinician focus groups and 18 in-depth interviews with adolescent mothers and their family members. Data were coded thematically, and direct content analysis was employed.

Results

The study identified the following issues facing adolescent parents: the transition to parenthood, the need for family support, difficulty accessing support, the difficulty for family members of providing support, and ideas about responsibility and adolescent autonomy.

Conclusion

Overall, these findings demonstrate the need for interventions that engage families and address barriers to accessing support, including relationship conflict and differing beliefs about responsibility and autonomy.

Implications

Interventions are needed for adolescent mothers in LMICs that mobilize family support. Clinicians who care for these patients need to be aware of the family context and the resources available where they practice.

Manifestations of Intergenerational Trauma During the Perinatal Period Among Adolescent Mothers in Lima, Peru: A Qualitative Analysis

Adverse childhood experiences have a lasting impact on health across the life course. The perinatal period offers a unique opportunity to rework problematic dynamics in families experiencing intergenerational trauma. This study explores the family dynamics that are activated during the perinatal period and considers the potential for intervention with adolescent parents and their families in Lima, Peru. This narrative analysis was part of a broader study that included focus groups and in-depth interviews. Of the ten adolescent mothers interviewed, four narratives were selected for presentation in this manuscript. These particular narratives were selected to illustrate the diversity of the experiences among this group and for the exceptional level of detail provided about their life experiences and family relationships. Narrative excerpts were analyzed in the context of the entire interview and the aggregate content of other interviews in order to explore both explicit and implicit meanings. This study identified critical relational shifts among adolescent parents and their families during the perinatal period. In one instance, adolescent parenthood created an opportunity for the family to come together. In the other cases, conflict escalated, relations grew distant, or both. These narrative data demonstrate that intergenerational trauma can interfere with family relationships in the context of adolescent pregnancy and prevent adolescent parents from accessing needed support from their families. Intervention with families could address the impact of trauma and improve communication and collaboration.

Orphans in post-conflict Liberia: Seeking care in fractured communities

Orphans in post-conflict settings have unique needs that have not been well-characterized. In post-conflict Liberia, maternal orphans are more likely to be without care than paternal orphans. This study examined the experiences of maternal orphans in Liberia, as they attempted to care for themselves and seek care from others, and the barriers they faced. In-depth interviews were conducted with 75 post-conflict Liberian orphans. We performed a secondary narrative analysis of interview transcripts from all maternal or double orphans (n = 17). We identified similar elements across narratives: traumatic loss, disconnection from family and community, and the desire for a savior. Female high-risk orphans were more likely to have formal substitute caregiving arrangements in which they were living with someone who was a relative or had been selected by a relative. Male orphans more commonly lacked arranged substitute care, but this allowed them to form relationships with substitute caregivers of their choosing. Sex also played a role in the provision of caregiving; substitute care was provided by women. Findings highlighted the syndemic relationship between poverty, violence, transactional sex, trauma, and substance use that traps high-risk Liberian orphans. Interventions are needed to improve access to mental health care, sober communities, housing, and education support. The need to integrate these services into indigenous institutions and address barriers related to stigma is explored.

Poor sleep Quality and Obstructive Sleep Apnea are Associated with Maternal Mood, and Anxiety Disorders in Pregnancy

BACKGROUND

Previous studies suggest sleep quality and obstructive sleep apnea (OSA) may be associated with psychiatric symptoms, including depression, anxiety, and posttraumatic stress disorder (PTSD). However, few studies have examined the relationship between sleep quality and OSA with maternal psychiatric symptoms during pregnancy, a state of vulnerability to these disorders.

OBJECTIVE

The objective of our study is to examine the association between poor sleep quality and sleep apnea with antepartum depression, anxiety, and PTSD among pregnant women.

METHODS

A cross-sectional study was conducted among women seeking prenatal care in Lima, Peru. Sleep quality was measured using the Pittsburgh Sleep Quality Index, and the Berlin questionnaire was used to identify women at high risk for OSA. Depression, generalized anxiety, and PTSD symptoms were measured using the Patient Health Questionnaire-9, Generalized Anxiety Disorder Assessment, and PTSD Checklist - Civilian Version. Multivariate logistic regression procedures were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI).

RESULTS

Approximately 29.0X% of women had poor sleep quality, and 6.2% were at high risk for OSA. The prevalence of psychiatric symptoms was high in this cohort with 25.1%, 32.5%, and 30.9% of women reporting symptoms of antepartum depression, antepartum anxiety, and PTSD, respectively. Women with poor sleep quality had higher odds of antepartum depression (aOR = 3.28; 95%CI: 2.64-4.07), generalized anxiety (aOR = 1.94; 95%CI: 1.58-2.38), and PTSD symptoms (aOR = 2.81; 95% CI: 2.28-3.46) as compared with women who reported good sleep quality. Women with a high risk of OSA had higher odds of antepartum depression (aOR = 2.36; 95% CI: 1.57-3.56), generalized anxiety (aOR = 2.02, 95% CI: 1.36-3.00), and PTSD symptoms (aOR = 2.14; 95%CI: 1.43-3.21) as compared with those with a low risk of sleep apnea.

CONCLUSIONS

Poor sleep quality and high risk of OSA are associated with antepartum depression, generalized anxiety, and PTSD symptoms among pregnant women. Further characterizations of the associations of these prevalent sleep, mood, and anxiety conditions among pregnant women could aid in evaluating and delivering optimal perinatal care to women with these comorbidities.

Mobile Technology Access and Use Among Adolescent Mothers in Lima, Peru: Mixed Methods Study

BACKGROUND

Research shows promise for the use of mobile health interventions to improve access to care for mothers and infants. Although adolescent mothers in particular are comfortable with technology and often face barriers to accessing care, data on the use of digital interventions with young mothers are limited.

OBJECTIVE

This study aims to examine technology access and use behavior among adolescent mothers in Lima, Peru, to inform the development of technology-mediated perinatal interventions for high-risk mothers and infants in low- and middle-income countries and other areas with limited access to care.

METHODS

This mixed methods study consisted of a phone survey about technology access (N=29), focus group discussions with clinicians (N=25), and semistructured in-depth interviews with adolescent mothers (N=10) and their family members (N=8) in Lima.

RESULTS

All adolescent mothers surveyed had access to a smartphone, and nearly half had access to a computer or tablet. However, participants reported a number of obstacles to consistent smartphone access related to the financial precarity of their situations. Examples of this included difficulty affording phone services, using shared plans, and losing smartphones because of theft.

CONCLUSIONS

These findings indicate that adolescent mothers are connected to technology, highlighting the potential scalability of technology-based health interventions for adolescent mothers in low- and middle-income countries while identifying barriers that need to be addressed.

Analyzing from Home: The Virtual Space as a Flexible Container

This manuscript explores the experience of teleanalysis for analyst and patient during the COVID-19 pandemic through the lenses of embodied intersubjective relating, the neurobiology of social engagement, and technologically mediated human interaction. At the beginning of the pandemic, many analytic dyads were embarking on remote work for the first time. More than a year later, we are facing the question of whether we will ever return to in-person work. In order to unpack this question, it is useful to consider how in-person analysis and in-person interaction more generally differ from remote interaction. Multiple nonverbal modalities are responsible for affective coregulation in intersubjective relating, including voice, body, and shared physical space. While conscious awareness tends to concentrate on auditory and visual inputs, other sensory inputs also impact affective experience. The impact of physical distance upon psychoanalytic treatment is compared with that of the couch. The shift in the balance of power introduced by teleanalysis is considered. Analyzing and being analyzed from home bend the frame of psychoanalysis, complicating notions about distance and intimacy and opening new spaces in which meaning can be cocreated. The COVID-19 pandemic presents an opportunity for psychoanalysis to engage more deeply with the questions raised by teleanalysis in order to enhance our understanding of its impact on treatment.

Psychometric properties of the Spanish version of the 10-item Connor Davidson Resilience Scale (CD-RISC) among adolescent mothers in Peru

The objective of this research is to assess the psychometric properties of the Connor-Davidson Resilience Scale (CD-RISC) in order to contribute to the literature identifying validated resilience measures in low-resource settings where individuals face significant adversity. This cross-sectional study included 789 adolescent mothers who delivered at a maternity hospital in Lima, Peru. The Spanish version of the 10-item CD-RISC was used to measure resilience. Internal consistency and construct validity were assessed by evaluating individual item characteristics as well as the association of CD-RISC score with symptoms of depression, anxiety and sleep disturbance. Exploratory factor analysis (EFA) was performed to test the factorial structure of the CD-RISC. The CD-RISC was found to have good internal consistency (Cronbach's alpha = 0.85). CD-RISC scores were positively associated with school attendance, financial hardship, and history of childhood abuse; scores were negatively associated with household dysfunction, depression, anxiety and poor sleep quality. The results of the EFA showed that the CD-RISC contained a two-factor solution, which accounted for 46% of the variance. Overall, these findings suggest that the Spanish-language version of the CD-RISC-10 is an adequate measure of resilience in this population. Further research is needed to incorporate culturally-specific constructs into resilience measures.

Suicide risk assessment: examining transitions in suicidal behaviors among pregnant women in Perú

The goals of this research were to characterize suicidal behavior among a cohort of pregnant Peruvian women and identify risk factors for transitions between behaviors. The World Health Organization Composite International Diagnostic Interview suicide questionnaire was employed to assess suicidal behavior. Discrete-time survival analysis was used to study the cumulative age-of-onset distribution. The hazard function was calculated to assess the risk of onset of each suicidal behavior. Among 2062 participants, suicidal behaviors were endorsed by 22.6% of participants; 22.4% reported a lifetime history of suicidal ideation, 7.2% reported a history of planning, and 6.0% reported attempting suicide. Childhood abuse was most strongly associated with suicidal behavior, accounting for a 2.57-fold increased odds of suicidal ideation, nearly 3-fold increased odds of suicide planning, and 2.43-fold increased odds of suicide attempt. This study identified the highest prevalence of suicidal behavior in a population of pregnant women outside the USA. Diverse populations of pregnant women and their patterns of suicidal behavior transition must be further studied. The association between trauma and suicidal behavior indicates the importance of trauma-informed care for pregnant women.

The psychometric properties of the 16-item version of the Prodromal Questionnaire (PQ-16) as a screening instrument for perinatal psychosis

Psychiatric illness can pose serious risks to pregnant and postpartum women and their infants. There is a need for screening tools that can identify women at risk for postpartum psychosis, the most dangerous perinatal psychiatric illness. This study used exploratory factor analysis (EFA) and Rasch item response theory (IRT) models to evaluate the psychometric properties and construct validity of the Spanish language version of the 16-item Prodromal Questionnaire (PQ-16) as a screening tool for psychosis in a population of pregnant Peruvian women. The EFA yielded a four-factor model, which accounted for 44% of the variance. Factor 1, representing "unstable sense of self," accounted for 22.1% of the total variance; factor 2, representing "ideas of reference/paranoia," for 8.4%; factor 3, representing "sensitivity to sensory experiences," accounted for 7.2%; and factor 4, possibly representing negative symptoms, accounted for 6.3%. Rasch IRT analysis found that all of the items fit the model. These findings support the construct validity of the PQ-16 in this pregnant Peruvian population. Also, further research is needed to establish definitive psychiatric diagnoses to determine the predictive power of the PQ-16 as a screening tool.

Trauma exposure and post-traumatic stress disorder in a cohort of pregnant Peruvian women

Women have a higher prevalence of post-traumatic stress disorder (PTSD) than men, with a peak during the reproductive years. PTSD during pregnancy adversely impacts maternal and infant health outcomes. The objectives of this study were to estimate the prevalence of antepartum PTSD symptoms in a population of pregnant Peruvian women and to examine the impact of number of traumatic events and type of trauma experienced. The Traumatic Events Questionnaire was used to collect data about traumatic exposures. The Post-traumatic Stress Disorder Checklist-Civilian Version (PCL-C) was used to assess PTSD. Multivariable logistic regression procedures were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Three thousand three hundred seventy-two pregnant women were interviewed. Of the 2920 who reported experiencing one or more traumatic events, 41.8% met criteria for PTSD (PCL-C score ≥ 26). A quarter of participants had experienced four or more traumas, and 60.5% of those women had PTSD. Interpersonal trauma was most strongly associated with PTSD (aOR, 3.20; 95% CI, 2.74-3.74), followed by unspeakable trauma (aOR, 2.87; 95% CI, 2.35-3.50), and structural trauma (aOR, 1.39; 95% CI, 1.15-1.67). These findings indicate the high prevalence of PTSD during pregnancy in the Peruvian population, which is relevant to other countries suffering from terrorism, war, or high rates of violence. This underscores the importance of screening for PTSD in pregnancy.

Supporting institutional caregivers in a children's home in rural south India

Orphans and other institutionalized children frequently have histories of maltreatment prior to entering institutional care. Better understanding the impact of these maltreatment experiences is essential to meeting the needs of these children. Institutional caregivers are challenged to address the unique and complex needs of these children. A team of child psychiatrists and mental health specialists visited a children's home in south India to provide consultation to the caregivers. The cases of two adolescent girls illustrate two distinct presentations following histories of significant maltreatment and early loss. One of the girls was significantly dysregulated. The other was struggling academically after leaving the home but was better able to regulate her affective states. The team recommended supporting the children's existing defensive structures and allowing them to speak about any past traumas on their own terms without being pushed to do so. The team also considered the self-regulating function of the cultural practices in which the children engaged and encouraged them to continue these activities.

A systematic review of randomized controlled trials of interventions designed to decrease child abuse in high-risk families

Child abuse is a global problem, and parents with histories of childhood abuse are at increased risk of abusing their offspring. The objective of this systematic review is to provide a clear overview of the existing literature of randomized controlled trials evaluating the effectiveness of interventions to prevent child abuse. PubMed, PsychINFO, Web of Science, Sociological Abstracts, and CINAHL were systematically searched and expanded by hand search. This review includes all randomized controlled trials (RCTs) of interventions designed to prevent abuse among mothers identified as high-risk. Of the eight studies identified, only three found statistically significant reductions in abuse by any measure, and only two found reductions in incidents reported to child protective services. While much has been written about child abuse in high-risk families, few RCTs have been performed. Only home visitation has a significant evidence base for reducing child abuse, and the findings vary considerably. Also, data from low- and middle-income countries are limited.

A qualitative analysis of parental loss and family separation among youth in post-conflict Liberia

Between 1989 and 2003, the Republic of Liberia experienced a brutal civil war. In 2008, the population was approximately 3.5 million people, and there were an estimated 340,000 orphans. Nearly 6000 more children were orphaned by the Ebola epidemic from 2014-2015. The goal of this research was to explore the impact of parental loss, identify moderating factors, and consider interventions that could help vulnerable youth in post-conflict societies following the loss of a parent. Seventy-five young people (age 13-18 years) in Monrovia, the capital city of Liberia, were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically. The loss of a parent or other primary caregiver had a significant impact on psychosocial and emotional health. The timing of the loss, strength of connection with the deceased parent, and relationship with surviving parent or substitute caregiver were all relevant factors. Children separated from living parents were functioning better than those whose parents were deceased. The case of Liberian children underscores the importance of early caregiver relationships and the difficulties children face when such relationships are disrupted. Children who did not experience stable early relationships suffered disconnection from their families and communities.

The global problem of child maltreatment: Perspectives on mechanisms of influence and illness presentation

Child abuse and neglect negatively impact both neurological and psychological development. Patterns of abuse are learned and repeated in families. Adverse childhood experiences are a risk factor for psychopathology later in life, including borderline personality disorder (BPD). BPD is prevalent in clinical populations in the United States, but its prevalence has not been well-documented in most other parts of the world. The aim of this paper is to explore the impact of culture upon the intergenerational transmission of childhood maltreatment and the clinical presentation of abused children. To facilitate this exploration, we will consider the cases of four adolescent girls in unique socioeconomic and cultural settings around the world: Liberia, El Salvador, India, and a Congolese immigrant in France. Each of these girls endorsed some features of BPD, but only two met full criteria. In societies in which externalizing behaviors are not acceptable, children may internalize their distress or separate from their families. Defining BPD in terms of internal experience makes it more difficult to identify, but it would allow for the inclusion of cases in which symptoms may manifest differently while the underlying problem is similar.

A qualitative analysis of factors impacting resilience among youth in post-conflict Liberia

BACKGROUND

In 2008, 5 years after the Liberian civil war ended, there were an estimated 340,000 orphans in Liberia, 18 % of the total child population of the country. Given that children make up half the population and that these children experienced significant trauma and loss both through direct exposure to the war and then to the Ebola epidemic, and indirectly as a result of the trauma experienced by their parents, the recovery of these children is essential to the recovery of the nation as a whole. The goal of this research was to identify factors contributing to resilience among youth in post-conflict Liberia. Resilience was defined as evidence of adaptive functioning and psychological health.

METHODS

Seventy-five young people (age 13-18) in the capital city of Monrovia, Liberia were recruited in 2012. Semi-structured interviews were conducted, and demographic data were collected. Interviews were then transcribed and coded thematically.

RESULTS

Forty-six of the participants were attending school, and 29 were not enrolled in school. Youth enrolled in school demonstrated greater adaptive functioning. This was particularly true for boys in any school setting and girls attending private school. Youth not attending school were more likely to have lost family members or become estranged from them, and many were also engaging in substance use. Emotion regulation, cognitive flexibility, agency, social intelligence and, in some cases, meaning-making were found in participants who showed resilient outcomes.

CONCLUSIONS

Caregiver relationships mediate the development of psychological capacities that impact resilience. These findings suggest that youth who have lost a caregiver, many of whom are not attending school, are experiencing a significant ongoing burden in terms of their daily functioning and psychological health in the post-war period and should be the focus of further study and intervention targeting substance use and community reintegration. Trial registration Partners Healthcare IRB Protocol# 2012P000367.

Assessment of the needs of vulnerable youth populations in post-conflict Liberia

OBJECTIVE

The study examined key informants' perceptions of the emotional impact of traumatic events, major problems, functional limitations and appropriate treatment settings for children, adolescents, and young adults in post-conflict Liberia.

METHOD

This research is a based on cross-sectional survey conducted between March 30, 2009 and April 30, 2009 in Liberia with 171 local key Liberian informants. Analysis was conducted using mixed methods. The findings we will report were collected in the qualitative portion of the survey.

RESULTS

We found that while different interventions were preferred for different types of young people, some interventions were mentioned for all youth and by all age and gender groups of key informants. These included counseling, education, and skills training. Also frequently chosen were housing, community reintegration, recreation, and medical care. In general, key informants reported similar concerns regardless of their ages or genders. Notable exceptions to this were in interventions for youth who joined fighting forces. Men over 50 were the only ones to recommend apology and reparations. Similarly, in recommendations for criminals and violent youth, a number of men mentioned prison, whereas the women did not.

CONCLUSION

Our findings suggest that the needs of post-conflict Liberian youth span a variety of domains, including physical, emotional, medical, psychological, and educational. These findings can be used to guide the development of treatment programs for these young people.

Contraceptive attitudes among inner-city African American female adolescents: Barriers to effective hormonal contraceptive use

STUDY OBJECTIVE

To better understand the contraceptive attitudes of low-income, inner-city African American female adolescents.

DESIGN

We conducted four focus group sessions with African American female adolescents.

SETTING

An urban, community health clinic serving low-income patients on Chicago's south side.

PARTICIPANTS

African American female adolescents (n = 15) between 14 and 19 years of age.

INTERVENTIONS

Focus group sessions lasting approximately 90 minutes in length were conducted using a pre-determined script with set probes and open-ended questions.

MAIN OUTCOME MEASURES

Qualitative analysis was conducted to identify major themes related to adolescents' contraceptive attitudes.

RESULTS

Six themes related to the contraceptive attitudes of these adolescents emerged: Concerns About Hormones, Concerns About Privacy, Concerns About Compliance, Limited Awareness of New Methods of Hormonal Contraception (HC), Preference for Condoms, and Acceptability of Emergency Contraception (EC). Overall, adolescents in these sessions expressed skepticism and unwillingness to use continuous methods of HC. For some adolescents, concerns about hormones, privacy, and compliance outweighed their concerns about pregnancy.

CONCLUSION

Concerns about perceived side effects and long-term health risks associated HC and privacy in obtaining contraception and reproductive health care, as well as concerns about ability to comply with daily and weekly HC regimens are common among African American female adolescents and may deter consistent HC use. Although condoms and EC appear to be highly acceptable among this group, adolescents also report a number of barriers to their consistent use. Efforts to reduce early, unintended pregnancy among African American youth should focus on addressing adolescents' HC-related concerns, improving access to EC, and helping female adolescents effectively negotiate condom use.