Supporting the Five Dimensions
As we considered our populations of low-income mothers of infants and toddlers (newly immigrated, Spanish-speaking Latina mothers and low-income, English-speaking mothers), we used findings from the existing literature and our own direct evidence to verify the five dimensions. As noted earlier, the linkages among poverty, stressors, maternal depressive symptoms, and negative child outcomes were well established by studies of mothers living in poverty. Considering both the presence of an MDE and depressive symptoms, Hammen's study yielded two findings relevant to targeting an intervention for maternal depression.53 First, the severity of the current depressive symptoms of mothers, not whether the mother had been formally diagnosed with depression, was associated with impaired interactions with their children. Second, children of mothers with elevated depressive symptoms showed greater negative outcomes than did children of mothers who had a formal diagnosis of depression but whose symptoms were in remission. Hammen concluded that regardless of the diagnostic status of the mother, the current severity of depressive symptoms was the most critical to mother–child interactions and child outcomes. Other researchers had established that the presence of symptoms limited function even when not severe enough for a clinical diagnosis.50
These findings suggested that intervention would be justified in mothers who had significant symptom severity but who had not met the diagnostic criteria for MDE. We knew that there was a high likelihood of finding low-income mothers with significant symptom severity and reasoned that an intervention that included all symptomatic mothers would reach the most at-risk children. If all mothers scoring above the cutpoint were included, mothers with the most severe symptoms and probable MDE would be identified as well. From a practical standpoint, it was unlikely that low-income mothers would have access to clinicians and unlikely that they could afford treatment. Offering a focused intervention in a destigmatized way by embedding it in EHS services seemed arguably the best way to reach these mothers and their infants and toddlers. Finally, the evidence that chronicity of maternal depressive symptoms and reduced maternal sensitivity were associated with negative child outcomes supported the decision to focus the intervention on limiting symptoms, increasing maternal sensitivity, and helping mothers provide appropriate developmental support to their infants or toddlers.
Designing the Study to Enhance Recruitment of Targeted Mothers
On the basis of evidence that mothers in poverty underuse mental health resources, we knew that there were barriers to gaining access to mothers.69 Therefore, we established a partnership with EHS, a federal enrichment program for infants and toddlers growing up in poverty. EHS already targets mothers living in poverty and provides them with child care, parent effectiveness training, and social services. The last dimension was important because we could not focus on the mental health needs of mothers unless they had help meeting housing, food, health care, and children's schooling needs. EHS requires a long application process including documentation of income and commitment by the mother to goals for herself and her family. The success of a mother in enrolling her child signaled a level of investment in the child and readiness for personal change that would maximize the acceptance of an intervention for depressive symptoms. The EHS staff believed that the project would help them meet federal performance standards requiring programs to support the mental health needs of their enrolled families. Finally, an important factor was that of stigma. By aligning with EHS, we could offer mental health care to mothers as part of a less-stigmatizing service and in a more confidential manner.
We conducted focus groups to gain more detailed information directly from mothers. Initially, we conducted four focus groups with a total of 25 English-speaking mothers of various ethnic backgrounds and ages. It was important to include mothers from all ethnic groups served by EHS to discover whether there was a common core of depressive symptoms and whether there were differences in acceptability and expression among mothers of different ethnic groups. Mothers confirmed that they were aware of the full spectrum of depressive symptoms and that these symptoms severely hampered their functioning. They felt emotionally isolated and physically unable to leave their homes. Moreover, their sadness, lethargy, and discomfort around others kept them from talking to EHS staff or using EHS parent resources. Although all of them were aware that something was wrong, they did not want to acknowledge it to themselves. Stigma was a factor in their silence. Rural mothers worried that their close-knit communities would find out and think they were “crazy,” whereas suburban mothers feared that seeking formal help might put a negative label on them and increase the isolation they felt already. The African American mothers were outspoken in feeling deep shame and failure about being depressed when they expected themselves to be strong for others. Nonetheless, there was a shared sense among all the mothers that the stigma of living in poverty was a shared adversity that united them, regardless of ethnicity, and made them reluctant to adopt another negative label (e.g., “mentally ill”). As one mother stated, “I'm a high school dropout, an unwed mother, I'm on welfare, and now you want me to say I'm depressed? Please! Not another bad label!” Mothers also reported that the pressure of day-to-day survival needs, changing schedules in their Temporary Aid to Needy Families Act–mandatede hourly jobs, reliance on public transportation, and difficulty in getting someone to watch the children were also barriers to seeking help for themselves. When asked what form an intervention needed to take to be helpful, mothers emphasized that the intervention needed to be confidential, convenient, flexibly scheduled, low profile, and empowering. These concerns led us to design our intervention as an in-home program delivered by nurses in partnership with EHS home-visiting services.
We then tested whether we could access these high-risk mothers by using traditional recruitment methods. We sent explanatory letters with consent forms, brief demographic questionnaires, and a depressive symptom screening questionnaire to every enrolled mother in one EHS program in a midsized northeastern city. We were stunned by the low return rate for screening questionnaires (5%) and an even lower rate for identifying symptomatic mothers (1%). We concluded that we were missing symptomatic mothers and barely saturating the available pool of potential participants. We met with our EHS program partner and developed a new procedure whereby we trained EHS staff to consent and screen mothers directly. The procedure increased the return of screening questionnaires (70%) and identification of mothers scoring above the cutoff of 16 on the Center for Epidemiologic Studies Depression scale (CES-D). The change in procedure was more labor intensive and required more investment of investigator and research staff time. The process, however, brought the research and site teams closer and promoted more dialogue and participation by the site in shaping the research design. Ultimately, the ongoing dialogue and close teamwork between EHS and the projects was essential in recruiting targeted mothers.
When targeting English-speaking mothers, we became aware that many of the U.S.-born infants and toddlers of newly immigrated Latinos were being enrolled in three of the southeastern U.S. sites. Latina EHS staff observed that the mothers of these children were coping with stressors of poverty, trauma, loss, adverse life issues, and rapid acculturation, and these mothers appeared to have depressive symptoms. Also, these mothers were isolated by not being able to speak English and had lost familial social support in the process of immigration. To target the intervention toward Spanish-speaking, newly immigrated Latina mothers, we enlisted the assistance of influential EHS staff who were part of the Latino community. In targeting this population, we first established that the depressive symptoms among Spanish-speaking mothers were similar to symptoms among English-speaking mothers.93 Therefore, we drew from previous work94,95 and instituted a process of decentering to establish that Spanish-speaking mothers were experiencing the depressive symptoms that our intervention was designed to reduce.
Decentering describes a process by which a construct is removed from the social context in which it has evolved.96 The literature described Latinos as presenting their depressive symptoms as somatic changes, such as pain, headaches, and stomach upset, rather than the thought and mood alterations consistent with U.S. diagnostic and symptom measurement devices.101 We were not sure that the construct of “depressive symptoms” was equivalent. Therefore, we brought the issue to the target population who would receive the intervention: Latina mothers, their husbands, and the bilingual community helpers who were working with them.
Sixteen Latina mothers who were identified by their EHS staff as symptomatic were prescreened on the CES-D for significant symptoms and invited to two different focus groups at the EHS program site. Participants in both focus groups were asked to talk about their struggle with depressive symptoms. The group facilitator did not use the term “depression” or refer to mental illness. Mothers used the term “depression”(depresión) and other identifiers—“deep sadness,”“my struggle,”“bad days,” and “sick days.” When given the categories of “thinking,”“feeling,”“actions,” and “body changes” and asked to identify in which of these domains they felt the symptoms most strongly, mothers immediately spoke of how their thinking processes were disrupted by depressive symptoms. They described being distracted, unable to think clearly, “in a cloud,” and unable to plan their work and stay focused on tasks. They readily spoke of changes in their ability to act (being immobilized and unable to leave their bed) and changes in their feelings (anger and irritability, sadness and tearfulness without an obvious reason). They spoke of having great difficulty with their toddlers around issues of setting limits and disciplining. They worried that any disciplinary actions would be seen as being a bad mother and yearned for guidance from older parents living abroad.
The mothers also identified several barriers to seeking help, such as lack of providers; shame about being depressed; fear of deportation; and for several who were familiar with the mental health system in their country, fear of being removed from their family, institutionalized, and being given electroshock therapy against their will. Seeking care for physical ailments and symptoms seemed safer to them, and they “hoped” that the providers would recognize that they were struggling with depressive symptoms. The women who had sought help were quick to say that their depressive symptoms had not been recognized or treated by the U.S. providers. Repetition of these themes in both focus groups affirmed that the mothers were experiencing similar feelings; that stigma, shame, and fear were formidable barriers to care; and that we needed to be sensitive to mothers' needs for privacy and confidentiality. The mothers readily acknowledged suicidal thoughts and in response to our questions about whether they would acknowledge these symptoms to a U.S. nurse, the mothers adamantly stated that providers needed to ask. They said, “If you don't, no one will, and we won't tell you about it unless you ask.” Mothers expressed great respect and trust for nurses and felt that they would try to answer any questions if the nurses asked respectfully.
Finally, the recent emphasis on postpartum depressive symptoms has brought attention to the importance of maternal depression in the child's first year of life. However, most of the mothers in these initial studies had toddlers. We elected to increase the window and screen mothers of newborns through 40-month-old EHS children. At the recent completion of our intervention study with Latina mothers, the age of children was 15.9 ± 11.5 (mean ± standard deviation) months, well beyond the postpartum period. Our clinical data from the intervention have indicated that the toddler era is stressful for mothers with depressive symptoms, particularly around issues of emotional regulation and discipline. Using the data from our pilot studies was valuable in helping us determine a targeted age of children that would allow us to understand when the symptomatic mothers we sampled were having difficulty.
In a narrower sense, decentering is the process of removing culture-specific idioms and terms that are embedded in the wording of a measurement instrument. This process occurs as an outcome of the translation and back-translation of an instrument from its source language into another language.97 In meeting the five dimensions associated with targeting, we also needed evidence that our screening tool (the CES-D) would correctly identify depressive symptoms in a Latino population. Data on the CES-D in Latinos were reasonably positive, with similar reliability and factor structures in comparative samples of Mexican Americans, blacks, and Anglos.98–100 In our initial evaluation of the CES-D, we ascertained that the translated version that had comparable psychometric data was the one that we chose to use. Some instruments have more than one translated version with variation among them in psychometrics. The comparability of the CES-D has been attributed to the presence of only one somatic depressive symptom item, which may control for overreporting of somatic depressive symptoms by Latino respondents.101 On the basis of these data, we chose the Spanish version as the screening instrument of the CES-D. As in our studies with English-speaking mothers, we anticipated that some mothers would not be literate and so we trained personnel to read the CES-D and other instruments aloud. Data from our current study of Latina mothers have confirmed that doing so was wise. Thirty percent of our sample (N = 80) had less than 6 years of formal schooling. Some mothers had as little as 3 years of formal schooling.
Verifying That Targeting Had Been Achieved
At an early point in our first intervention study with Spanish-speaking, newly immigrated Mexican mothers, we were able to verify that our approach to targeting was effective in reaching the most at-risk mothers. We hypothesized that if our recruitment methods were reaching the targeted population, data would confirm that poverty and its associated stressors eroded self-efficacy, increased parental conflict and maternal depressive symptoms, and negatively affected mother–child interactions.
We gathered data from 25 asymptomatic mothers and 32 mothers (N = 57) who scored over the standard cutpoint of 16 on the CES-D. We asked them about demographic characteristics (maternal age and years of education), social support (employment outside the home, no partner at home in the home, moved within the last year), family conflict, and maternal burdens (children's chronic health, access to transportation, debt, legal difficulties). Using standardized instruments,f we also interviewed them about acculturation, maternal health status, maternal self-efficacy, mother–child interactions, and depressive symptom severity. Table 1 presents descriptive data on the variables.
Table 1. Sample characteristics (N = 57)
|Variable||Mean or %||SD|
| Mother's age||27.47||5.34|
| Years of education|| 8.79||2.78|
| Works outside home||26%|| |
| Not living with spouse/partner|| 9%|| |
| Years in United States|| 5.93||3.86|
| No English skills (SASH = 4 of 20)||67%|| |
| Low acculturation to Anglo-American norms (PAS = 10 of 30)||37%|| |
| ≥2 children under age 6||60%|| |
| Child health/learning problem||32%|| |
|Financial stress||39%|| |
| Family conflict|| 8.09||3.23|
| High family conflict (≥10)||21%|| |
|Self-reported health (1 = poor …|
| 5 = excellent)|| 2.77||1.07|
|General self-efficacy||59.25||12.59 |
| CES-D score||16.60||14.73 |
| CES-D score >16||46%|| |
| Maternal parenting behavior|
| Modified parental distress score (PSI)||14.67||5.14|
| Parent–child dysfunctional interaction (PSI)||21.86||7.22|
| Modified total stress score (PSI)||36.53||10.64 |
| HOME (verbal and emotional)|| 9.53||1.95|
| HOME (avoidances of restrictions and punishment)|| 5.98||1.23|
| HOME (organization of environment)|| 4.98||0.86|
| HOME (play materials)|| 6.96||1.75|
| HOME (maternal involvement)|| 4.61||2.02|
| HOME (variety)|| 3.35||1.41|
| Total HOME score||35.42||5.98|
We then estimated three sets of regressions to identify the pathways leading to a loss of self-efficacy: (1) primary risk factors for financial stress, (2) the relationship between financial stress and family conflict, and finally (3) the relationship between family conflict and self-efficacy (Table 2). In our last set of regressions, we evaluated the association between depressive symptoms and total parenting stress and the quality of the home environment (Table 3). Using two-sample independent groups t-test, we also evaluated unadjusted differences in mean scores on each subscale of the PSI and HOME for mothers with (CES-D ≥ 16) and without (CES-D < 16) substantial depressive symptoms (Fig. 1).
Table 2. Regression results on financial burdens, family conflict, and maternal self-efficacy
|Variable||Model 1 Financial stress||Model 2 Family conflict||Model 3 Self-efficacy|
| Mother's age||−0.01||0.06||−0.05||0.08|| 0.55||0.26** |
| Years of education|| 0.07||0.11|| 0.07||0.16||−1.80||0.54***|
| Works outside home||−0.15||0.65|| 1.18||0.95|| 11.53||3.19***|
| No English skills|| 1.48|| 0.74**|| 1.54||1.00||−5.15||3.39 |
| ≥2 children under age 6||−0.17||0.61|| 1.07||0.85|| 0.78||2.84 |
| Child health/learning problem|| 1.16|| 0.63*||−0.65||0.92||−3.01||3.04 |
|Financial stress||—||—|| 1.62|| 0.90*||−1.70||3.07 |
|Family conflict||—||—||—||—||−1.22||0.47** |
|N|| ||57 || ||57 || ||57 |
|Pseudo-R2/R2|| ||0.10|| ||0.20|| ||0.44 |
Table 3. Regression results on CES-D
|Mother's age||−0.40 ||0.25 |
|No partner at home||8.89||4.55* |
|Child health/learning problem||6.85||2.87** |
|Financial stress||−0.81 ||2.94 |
|General self-efficacy||−0.40 ||0.11***|
|Low psychological acculturation||5.71||2.81** |
|N|| ||57 |
|R2|| ||0.63 |
Our results demonstrated that we were correctly targeting a population in which poverty was affecting maternal mental health in the expected fashion. We found that worry or frustration with financial debt was most strongly associated with a lack of English language skills (odds ratio = 4.42; P < 0.05). Families who had one or more children with a chronic health problem or learning disability were nearly three times more likely to report concerns about financial debt (odds ratio = 3.19; P < 0.10). Maternal characteristics (e.g., age and years of education) and social support had no significant association with the mother's sense of financial burden.
Financial worries, in turn, were significantly associated with the levels of family conflict reported by the mothers. The presence of financial burdens was associated with an average increase of 1.7 points on the family conflict scale (range, 5–20). A lack of English language abilities and the presence of two or more children younger than 6 years also exacerbated the potential for family conflict. Other maternal burdens, maternal characteristics, and social support were not associated with higher family conflict scores. Although maternal characteristics and social supports had little influence on financial stress or family conflict, they were strongly associated with maternal self-efficacy. Finally, as hypothesized, higher family conflict levels were associated with lower levels of maternal self-efficacy.
Having established the linkages among financial worries, family conflict, and maternal self-efficacy, we examined the relationship between maternal self-efficacy and depressive symptoms. Though the causal direction could not be confirmed with our cross-sectional data, maternal self-efficacy explained 31% of the variance in CES-D scores (results not shown). Adding family conflict to the regressions increased the explained variance to 49%. The remaining factors (i.e., social support, multiple family burdens, and acculturation) hypothesized to affect depressive symptoms were not nearly as influential as self-efficacy and family conflict. The presence of multiple family burdens (e.g., child health/learning problems, financial worries, transportation needs, or legal/social service assistance needs) also approached significance in each model.
Finally, in our analyses of depressive symptoms and mother–child interactions, we found significantly higher levels of maternal distress and dysfunctional parent–child interactions among depressed (CES-D ≥ 16) mothers than among nondepressed (CES-D < 16) mothers (Fig. 1). We also found that depressed mothers reported a significantly less stimulating and affirming home environment than non-depressed mothers. The aspects of the home environment that varied most strongly by depressive symptoms were verbal/emotional stimulation and maternal involvement.
In results not shown, these associations continued to be strong when adjusted for potential confounders, such as maternal burden, self-efficacy, family conflict, and acculturation. With the exception of maternal burden, all other factors had only indirect associations with mother–child interactions through their effects on depression.
This set of analyses demonstrated that Latina immigrant mothers who had limited English skills and faced multiple family burdens (e.g., one or more children with a chronic health problem or learning disability, financial debt, or transportation problems) were at risk of experiencing family conflict and subsequently developing both a low sense of self-efficacy and symptoms of depression. Thus, an intervention targeting mothers with these characteristics and designed to promote mother's self-efficacy by empowering her with various life skills (e.g., language skills, skills to navigate the U.S. health care and the public transportation systems, and the skills needed to garner supportive resources for her child in the United States) could promote a reduction in maternal depressive symptoms and a subsequent improvement in parenting stress and the quality of the home environment.