THEORIZING ABOUT RESILIENCE AND ITS RELATIONSHIP TO DEPRESSION
AMONG RURAL LOW-INCOME MOTHERS: MIXED METHODS APPROACHES
By
Laurie Anne Bulock

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Human Development and Family Studies – Doctor of Philosophy
2013

ABSTRACT
THEORIZING ABOUT RESILIENCE AND ITS RELATIONSHIP TO DEPRESSION
AMONG RURAL LOW-INCOME MOTHERS: MIXED METHODS APPROACHES
By
Laurie Anne Bulock
Depression is a devastating disease, especially when the depressed individual is a mother.
Research interest in maternal depression is justified when considering the far-reaching
consequences experienced by children and families when mothers suffer from depressive
symptoms. A contextual understanding of maternal depression is needed and can emerge when
looking longitudinally at patterns of depression and their influences on personal and family life
contexts. This dissertation consists of two studies, each of which used a longitudinal, mixed
methods approach to explore the variability in longitudinal depression patterns among rural lowincome mothers. Ecological and resilience approaches provided the theoretical frameworks to
better understand risk and protective factors associated with each depression pattern.
In the first study, a resilience lens was employed to identify resilience processes adapted
by the mothers and their families. Consistent with a concurrent triangulation design, quantitative
analyses were conducted to place mothers within longitudinal depression patterns for subsequent
in-depth analysis using grounded theory techniques. Similar themes emerged among all of the
participants in the study. However, the picture of resilience expressed within these themes
varied by depression pattern, as did the nature and the number of sources of stress and sources of
strength.
In the second study, MANOVA and MANCOVA procedures provided insight into how
the risk and protective factors organized themselves amid the depression patterns. Mothers in
the high, worsening, and erratic patterns experienced more health problems, child health

problems, financial strain and food insecurity. Mothers in the low and improving patterns
experienced fewer risk factors, and reported a higher sense of parental confidence and social
support. Qualitative analyses provided further explanation and support for the quantitative
findings, and provided further insight into the relationships among the risk factors and the
interactive ways the mothers tapped into protective factors.
The findings of the two studies highlight the complexity of risk and resilience processes
in the context of maternal depression among rural low-income women. For mothers with
persistently high or worsening depression, multiple risk factors were associated, such as health
problems, financial strain, and food insecurity. Despite such risks, important protective
processes, or sources of strength, made a difference in the lives of the mothers and included a
positive perspective, parenting strengths, social support, and perceived family strengths.
Implications for research, policy and practice are discussed.

DEDICATION
This dissertation is dedicated to my husband, my children, and many other family
members and friends who supported me. This journey to research and write this dissertation can
be likened to running a marathon. The race was long and full of unexpected twists, turns, road
blocks, and life and family hurdles. However my husband, Bryan, was my rock at those times
when I didn’t think I could finish. His belief in me is unfathomable. My children, Corey,
Sydney, and Max, have been incredibly patient through it all. My biggest prayer is for their
resilience after the life and health battles that each of them, and our family has faced.
Before her illnesses, my mother was a huge resource when my children were smaller.
She watched and loved them when I needed to focus on research. I could not have done all this
without her and am so glad that God kept her with us after everything she has been through. I
also cannot thank my father, and my mother and father-in-law enough for the ways they have
supported my family and me through very difficult times. There were many other family
members and friends who encouraged me along the way. Their cheering along the sidelines was
a lifeline of motivation throughout the marathon.

iv

ACKNOWLEDGMENTS

I wish to thank Dr. Barbara Ames, my advisor, mentor, and committee chair. She has
supported and encouraged me in innumerable ways throughout my graduate education, and
especially through the dissertation process. Her mentorship continually led me to pursue
opportunities for networking and professional development. I am indebted to Dr. David Imig,
who provided the opportunity to become involved with the Rural Families Speak project. I also
want to thank him for his critiques and well-placed questions in the writing of the second study
(Chapter 4). Those questions were pivotal and created clarity for presenting the large number of
findings in a cohesive way. I am appreciative of Dr. John Mooradian for his support and
encouragement through tough times, and for his insight on resilience that were instrumental for
revisions and the final product. I am grateful to Dr. Marsha Carolan for stepping in to fill a vital
role on my committee after the loss of Dr. Tom Luster. Her expertise on qualitative and mixed
methods analyses was valuable. I want to thank Dr. Tom Luster for our conversations on
resilience which led to much of my work, including this dissertation. Last, I am thankful to the
women and families who participated in the Rural Families Speak study. Though I didn’t have
the privilege of meeting them, their stories of resilience kept me grounded and connected.
Finally, I want to acknowledge that this research was supported in part by
USDA/CREES/NRICGP Grants—2001-35401-10215, 2002-35401-11591, 2004-35401-14938.
Data were collected in conjunction with the cooperative multi-state research project NC-223/NC1011 Rural Low-Income Families: Tracking Their Well-Being and Functioning in the Context of
Welfare Reform.

v

TABLE OF CONTENTS

LIST OF TABLES ..................................................................................................................... x
LIST OF FIGURES ................................................................................................................... xi
CHAPTER 1
INTRODUCTION ..................................................................................................................... 1
Background .................................................................................................................... 1
Purpose Statement .......................................................................................................... 2
Statement of the Problem ................................................................................................ 3
Significance of the Study ................................................................................................ 4
Study Design .................................................................................................................. 5
Dissertation Structure .......................................................................................... 6
Dissertation Sample ............................................................................................. 9
Rural Families Speak Findings Related to Depression ................................................... 12
Theoretical Frameworks ............................................................................................... 14
Research Questions and Hypotheses .............................................................................. 17
CHAPTER 2
LITERATURE REVIEW ......................................................................................................... 19
Introduction ................................................................................................................... 19
Ecological and Resilience Frameworks ......................................................................... 21
Ecological and Resilience Processes at the Individual Level .............................. 23
Proximal processes ................................................................................. 24
Person .................................................................................................... 26
Context ................................................................................................... 27
Time ....................................................................................................... 28
Ecological and Resilience Processes at the Family Level ................................... 29
Proximal processes – Resource management .......................................... 29
Proximal processes – Decision making ................................................... 31
The concept of family in relation to family ecology and family
resilience ................................................................................................ 32
Family environmental context ................................................................ 33
The role of time ...................................................................................... 35
Summary .......................................................................................................... 36
Depression .................................................................................................................... 37
Genetic Vulnerabilities ...................................................................................... 38
Neurobiological Vulnerabilities ......................................................................... 39
Cognitive Vulnerabilities .................................................................................. 45
Interpersonal Vulnerabilities ............................................................................. 49
Summary .......................................................................................................... 50
Depression in Women and Factors Associated with Maternal Depression ..................... 51
Depression in Women ....................................................................................... 51
vi

Depression and Parenting Confidence ............................................................... 53
Depression and Social Support .......................................................................... 56
Maternal Depression and Economic Risk .......................................................... 57
Family Challenges in the Context of Welfare Reform ................................................... 59
Rural Families Speak Findings Related to Depression ................................................... 61
Summary of the Literature Review ............................................................................... 62
CHAPTER 3
STUDY 1: PICTURES OF RESILIENCE AMONG RURAL LOW-INCOME MOTHERS:
A MIXED METHODS STUDY .............................................................................................. 64
Abstract ....................................................................................................................... 64
Introduction .................................................................................................................. 65
Resilience Framework ...................................................................................... 66
The Importance of Perception ........................................................................... 67
Social Support Matters ...................................................................................... 68
The Present Study ............................................................................................. 69
Method ......................................................................................................................... 70
Sample .............................................................................................................. 70
Data Collection .................................................................................................. 72
Analytic Approach ............................................................................................ 72
Step One ................................................................................................. 73
Step Two ................................................................................................ 74
Step Three .............................................................................................. 75
Findings ....................................................................................................................... 77
“Stable Low” Depression .................................................................................. 79
“Stable Moderate” Depression .......................................................................... 80
“High” Depression ............................................................................................ 82
“Improving” Depression .................................................................................... 83
“Worsening” Depression ................................................................................... 85
“Erratic” Depression ......................................................................................... 87
Discussion .................................................................................................................... 89
A Cultural Role in Resilience Processes ............................................................ 92
Limitations ........................................................................................................ 93
Implications for Policy and Practice .................................................................. 94
Conclusions .................................................................................................................. 96
CHAPTER 4
STUDY 2: INVESTIGATING RURAL LOW-INCOME MOTHERS’ LONGITUDINAL
DEPRESSION PATTERNS USING A RISK AND RESILIENCE FRAMEWORK ................ 97
Abstract ........................................................................................................................ 97
Introduction .................................................................................................................. 98
Common Risk Factors of Maternal Depression .................................................. 99
Common Protective Factors Associated With Maternal Depression ................. 101
Hypotheses ................................................................................................................. 102
Methods ...................................................................................................................... 103
Sample ............................................................................................................ 104
vii

Data Collection ................................................................................................ 106
Measures ......................................................................................................... 107
Maternal depression.............................................................................. 107
Risk Factors .................................................................................................... 109
Perceived economic strain .................................................................... 109
Mothers’ number of health problems .................................................... 110
Average number of child health problems ............................................. 110
Average monthly income ..................................................................... 110
Food insecurity ..................................................................................... 110
Protective Factors ............................................................................................ 111
Marital status ........................................................................................ 111
Parental confidence .............................................................................. 111
Parental support .................................................................................... 111
Analysis Strategy ............................................................................................ 112
Results ........................................................................................................................ 114
The Story Behind the Numbers for Maternal Health ........................................ 119
Child Health Problems can be a Risk Factor .................................................... 121
Financial Strain and its Relationship with Food Insecurity and other Stressors . 123
Seeing Themselves as Confident in their Parenting .......................................... 127
Affective Aspects of Parental Confidence ............................................ 127
Instrumental Aspects of Parental Confidence ....................................... 128
Social Support for the Parenting Role .............................................................. 130
Discussion .................................................................................................................. 134
Multiple Risks are Related to Multiple Morbidity............................................. 135
Depression and the Role of Parental Confidence ............................................. 136
Depression and its Complex Relationship with Social Support ........................ 137
Limitations ...................................................................................................... 138
Implications for Policy, Practice, and Research ............................................... 139
Conclusions ................................................................................................................ 141
CHAPTER 5
DISCUSSION OF THE TWO STUDIES ............................................................................... 142
Introduction ................................................................................................................ 142
Multiple Risks are Related to Multiple Morbidity ....................................................... 144
Intentional Activation of Sources of Strength .............................................................. 146
The Puzzle of the Women in the Moderately Depressed Pattern .................................. 148
A Cultural Role in Resilience Processes ...................................................................... 149
Theoretical Implications .............................................................................................. 150
Limitations ................................................................................................................. 155
Implications for Research, Policy and Practice ............................................................ 157
Lessons Learned ......................................................................................................... 161
Conclusions ................................................................................................................ 162
APPENDICES ....................................................................................................................... 164
Appendix A: Wave One Survey Protocol ..................................................................... 165
Appendix B: Wave Two Survey Protocol .................................................................... 189
viii

Appendix C: Wave Three Survey Protocol .................................................................. 223
REFERENCES ...................................................................................................................... 265

ix

LIST OF TABLES

Table 1.1. Demographic Variables Characterized By Rural Mothers’ Depression Patterns ...... 10
Table 1.2. Sample for Each Depression Pattern ........................................................................ 11
Table 1.3. Research Questions and Hypotheses of the Dissertation and Studies ....................... 17
Table 2.1. Ecological and Resilience Concept Matrix .............................................................. 23
Table 3.1. Demographic Variables Characterized by Rural Mothers’ Depression Patterns ........ 71
Table 3.2. Number of Mothers in Each Depression Category................................................... 73
Table 3.3. Primary Themes for Each Depression Pattern ......................................................... 78
Table 4.1. Characteristics of Rural Families Speak Wave 1 Sample
and Present Study Sample ..................................................................................... 106
Table 4.2. Numbers And Percentages Of Mothers In Each Depression
Category For Each Wave ....................................................................................... 108
Table 4.3. Demographic Variables Characterized By Rural Mothers’ Depression Patterns .... 115
Table 4.4. Risk and Protective Factors Distributed By Mothers’ Depression Patterns ............ 119
Table 5.1. Ecological and Resilience Concept Matrix with Study Results ................................ 152
Table A.1. Knowledge of Community Services ....................................................................... 177
Table A. 2. Life Skills Assessment .......................................................................................... 178
Table A. 3. Feelings About How Things Are Going ................................................................ 179
Table B. 1. Knowledge of Community Services ...................................................................... 211
Table B. 2. Life Skills Assessment .......................................................................................... 212
Table B. 3. Feelings About How Things Are Going ................................................................ 213
Table C. 1. Knowledge of Community Services ...................................................................... 247
Table C. 2. Feelings About How Things Are Going ................................................................ 264

x

LIST OF FIGURES

Figure 1.1. Mixed Methods Designs of Rural Families Speak and this Dissertation ................... 6
Figure A. 1. The Parenting Ladder .......................................................................................... 180
Figure B. 1. The Parenting Ladder ........................................................................................... 214

xi

CHAPTER 1
INTRODUCTION
Background
Social science has increasingly focused on the correlates and detrimental effects of
depression in mothers. Such interest is justified when considering the far-reaching consequences
experienced by children and families when mothers suffer from depressive symptoms. The child
development literature alone has produced numerous studies on the relationship between
maternal depression and poor child outcomes, such as poor child health (Casey, Goolsby,
Berkowitz, Frank et. al, 2004), child disruptive behaviors (Gross, Shaw, Burwell & Nagin,
2009), and deficits in cognition and behavioral regulation among infants and young children (for
a more extensive review see Hammen, 2003).
Studies of low-income mothers have identified risk factors associated with depression
among this population, including financial stress and strain (Casey, Goolsby, Berkowitz, Frank,
et. al, 2004). Rural mothers in particular experience life demands that have been found to be
associated with depression symptoms, such as employment instability (Dolan, Richards, Sano,
Bauer, & Braun, 2005; and Kim, Seiling, Stafford & Richards, 2005), and household food
insecurity (Olson, Anderson, Kiss, Lawrence, & Seiling, 2004). Other challenges rural low
income mothers and families face include isolation, limited employment and educational
opportunities, and limited childcare options (Ames, Brosi & Damiano-Teixeira, 2006).
Most of the literature to date has examined maternal depression from a risk-only
perspective. However, a risk and resilience perspective helps the field understand why some
women, under similar risk conditions, do not experience depression. A risk and resilience lens
would include examination of the buffers and coping mechanisms mothers and their families
develop to off-set the demands related to mothers’ depressive symptoms. A few studies that
1

have operationalized a resilience approach have identified social support as a coping mechanism
some mothers employ in response to stressors (Brown, Brody & Stoneman, 2000; Casey, et.al.,
2004; Coiro, 2001; Dennis, Parke, Coltrane, Blacher, & Borthwick-Duffy, 2003; Ennis, Hobfall
& Schroder, 2000; Jackson, 1998, 1999; Jackson & Huang, 1998; Ross, 2000; Siefert, Heflin,
Corcoran, & Williams, D. 2004; Taylor, Rodriguez, Seaton, & Dominguez, 2004). The present
studies continue previous work analyzing data from a multi-state sample of rural low income
women, and utilize a risk and resilience lens to glean an understanding of the interplay between
mothers’ depression patterns, life stressors, and individual and family protective factors and
coping processes (i.e., individual and family resilience).
Until recently, the majority of the research on maternal depression has been crosssectional and quantitative in design. Consequently, less is known about the variability of
depression symptoms in community samples of mothers over time, and about the meanings and
internal relationship dynamics families develop when mothers experience depression on a longterm basis. While more recent research has incorporated a longitudinal approach to understand
the interactions between mothers’ depression patterns, family dynamics and child outcomes
(Gross, Shaw, Burwell & Nagin, 2009; Smith & Howard, 2008), they are still based mainly on
quantitative analyses, which may miss other important factors that contribute to the complex
interplay among individual and family risk and protective processes.
Purpose Statement
The overall purpose of these exploratory studies is two-fold: to explore qualitatively and
quantitatively the nature of rural low-income mothers’ longitudinal depression patterns; and to
build upon a risk and resilience theoretical framework. This dissertation uses data from the
NC1011 Rural Families Speak project, a longitudinal, mixed method, multistate investigation of

2

the well-being of rural low-income mothers and their families in the context of welfare reform.
Longitudinal depression patterns have been identified in the Rural Families Speak quantitative
data set, but have not been formally investigated. The present studies explore the contextual
nature of the depression patterns, and explore the distribution of risk and resilience factors
among the patterns. The results of these explorations have implications for furthering our
understanding of resilience frameworks.
Statement of the Problem
The negative effects of poverty and rural living on maternal mental health and family
functioning are important concerns for family professionals and policymakers. Rural working
poor families have multiple challenges, and the requirements of welfare reform laws may further
complicate rural life. It is imperative, therefore, to gain a better understanding of how rural
working poor individuals and families cope with life challenges. While many studies have
focused on the risks associated with rural poverty (Ames, Brosi & Damiano-Teixeira, 2006;
Kim, Geistfeld & Seiling, 2003; Kim, Seiling, Stafford & Richards, 2005; Olson & Bove, 2005;
USDA, 2002; see also the Rural Families Speak web site,
http://fsos.che.umn.edu/projects/rfs.html), fewer have focused on individual and family
resilience factors and processes associated with rural family life (Parra-Cardona, Bulock, Imig,
Villarruel & Gold, 2006; Vandergriff-Avery, Anderson & Braun, 2004). A risk and resilience
perspective provides practitioners and policy stakeholders with another lens to learn about the
mechanisms by which many rural mothers and their families who have experienced depression
have been able to maintain competent functioning in an uncertain time of welfare reform and
economic change.

3

Significance of the Study
Many studies focus on maternal depression either as a response to stressors, such as
economic hardships and strains (Mirowsky & Ross, 1990; Pearlin, Menaghan, Lieberman, &
Mullan, 1981; Pearlin & Schooler, 1978; Ross & Mirowsky, 1989; Turner & Lloyd, 1999a,
1999b), or as a risk factor for negative child outcomes (Brown, Brody & Stoneman, 2000; Casey,
Goolsby, Berkowitz, Frank, Cook, Cutts, et. al., 2004; Dennis, Parke, Coltrane, Blacher, &
Borthwick-Duffy, 2003; Hammen, 2003; Hammen & Brennan, 2003; Jackson, 1998; Luthar,
D’Avanzo & Hites, 2003). Additionally, many studies are cross-sectional in nature (Brown,
Brody & Stoneman, 2000; and Casey, Goolsby, Berkowitz, Frank, Cook, Cutts, et.al, 2004),
which provides a snapshot of maternal depression. There are fewer longitudinal studies that
focus on factors related to changes or improvements in mothers’ depression over time (Avison,
Ali, & Walters, 2007; and Moen, Robison & Dempster-McClain, 1995).
While the link between lower socioeconomic status and maternal depression has been
made clear in the literature, the causal direction is more difficult to determine. Longitudinal
quantitative studies aiming to untangle the causal relationship suggest that social causation
models are supported in the data available (Eaton, Muntaner, Bovasso & Smith, 2001; Monroe,
Slavich & Georgiades, 2009; Simmons, Braun, Charnigo, Havens & Wright, 2007). That is,
social conditions such as chronic poverty, limited access to resources and supports, and family
and life stressors place individuals at higher risk for health and mental health struggles
(Simmons, Braun, Charnigo, Havens & Wright, 2007). Much has been learned about maternal
depression from quantitatively based studies. However, given the complex nature of maternal
depression and its relationship to healthy family functioning, the present studies use a

4

longitudinal mixed methods design to gain a better understanding of the relationship and
functioning dynamics of depression and its influence on the family.
Study Design
The specific mixed methods design of the larger Rural Families Speak project is
consistent with a concurrent triangulation design (Creswell & Plano Clark, 2007; Creswell, Plano
Clark, Gutmann, & Hanson, 2003) in which the quantitative and qualitative data were collected
each year (for three waves of data collection), but the two data sets are kept separate so that
members of the multi-state research team are able to analyze either or both of the data sets
according to their research questions.
This dissertation consists of two mixed methods studies. Both also are consistent with a
concurrent triangulation design (Creswell & Plano Clark, 2007; Creswell, Plano Clark, Gutmann,
& Hanson, 2003) as described above; however integration occurs at different stages in each
study. In the first study, integration of methods occurs at the analysis stage in that the
quantitative data are used to divide mothers according to longitudinal depression patterns for
qualitative analyses (described as chapter three below) and interpretation. In the second study
(described as chapter four below) integration occurs at the interpretation stage in which
“statistical trends are supported by qualitative themes” (Creswell, Plano Clark, Gutmann, &
Hanson, 2003, p. 233). Findings from both studies are further integrated and discussed in
chapter five. Figure 1.1 provides a visual representation of the relationships between the Rural
Families Speak design, and the designs of the two studies in this dissertation.

5

Figure 1.1. Mixed Methods Designs of Rural Families Speak and this Dissertation
Rural Families Speak (N = 413)
QUAN
Data collection

QUAL
Data collection

+

Study 1 (Chapter 3)
quan
data
analysis

QUAL
data
analysis

QUAL
interpretation

QUAL + QUAN

Study 2 (Chapter 4)
QUAN
data
analysis

QUAN
results

qual
data
analysis

qual
results

Interpretation
(Chapter 5)

Validate
QUAN results
with qual
results

Note: QUAL = qualitative; QUAN = qualitative. Upper case letters denote primary method for a
study. (+) indicates methods that occur at the same time; () indicates methods that occur in a
sequence (Creswell & Plano Clark, 2007).
Dissertation Structure
The following outlines the structure of this dissertation:
Chapter one establishes the purpose and significance of this dissertation, providing an
overview of maternal depression, and an overview of the theoretical frameworks informing the

6

studies. The structure of the mixed methods design for the dissertation and for each study is
introduced.
Chapter two consists of an in-depth discussion of the ecological and risk and resilience
frameworks, as they provide the theoretical framework for the study, as well as a comprehensive
literature review of maternal depression.
Chapter three consists of the first manuscript (study 1), a mixed methods longitudinal
study examining a sample of mothers who participated in all three waves of data collection. The
purpose of this study is to glean an understanding of the contextual influences on mothers’
depression patterns over time.
Maternal depression was measured using the Center for Epidemiologic Studies
Depression Scale (CES-D), which was designed to measure symptoms of depression in the
general public (Radloff, 1977). Analysis was conducted in three steps. First, using the
quantitative data set, the mothers’ depression scores were coded into four categories according to
Seligman’s recommendation (1998):
1) nondepressed (depression score of 0-9)
2) mildly depressed (depression score of 10-15)
3) moderately depressed (depression score of 16-24)
4) severely depressed (depression score over 24)
This categorization was used for the depression scores for each wave. This allowed a direct
comparison of the levels of depression across all three years. For the second step, each mother
was placed into one of six longitudinal “depression patterns”:


“Stable low” pattern consisted of mothers who reported depressive symptoms consistent
with categories one and two (nondepressed and mildly depressed), and who remained in

7

those low categories across time (low  low  low).


“Stable moderate” pattern consisted of mothers who reported depressive symptoms in the
moderately depressed range over time (mod  mod  mod).



“High depression” pattern consisted of mothers whose depression remained in the
severely depressed category all three waves (high  high  high).



“Worsening depression” consisted of mothers experiencing few depressive symptoms
during the first wave, but more severe depressive symptoms over the next two waves
(low  high  high).



“Improving depression” consisted of mothers who experienced high depression the first
wave, but reported fewer symptoms by the third wave (high  low  low).



Finally, for some mothers the pattern was “erratic”, such that symptom levels changed
dramatically each year of data collection (very high  very low  very high).

The third step involved qualitative analysis of three cases from each of the depression
patterns (18 cases total). For each case, the mothers’ transcripts for all three years were analyzed.
Thus a total of 54 transcripts were coded and analyzed (three mothers X six depression patterns
X three transcripts). The objective of the qualitative analysis is to employ a grounded theory
approach (LaRossa, 2005) to gain an understanding of the context in which these patterns occur,
and the ways in which those patterns relate to family relationships, functioning, and meanings, as
well as risk and resilience processes.
Chapter four consists of the second manuscript (study 2), an exploratory mixed method
study in which the sample was divided according to the depression patterns described above, and
bivariate analyses were conducted to understand the ways in which risk and resilience factors
8

organized themselves among each pattern of depression. These results were compared to
analyses of risk and resilience factors that were relevant for the entire Rural Families Speak
sample (N = 413). For instance, in previous research (Bulock, 2004) household income, life
satisfaction, and social support were factors associated with depression among the entire sample.
However mothers’ employment status was a mediating variable. It was hypothesized that
conducting analyses that took mothers’ depression patterns into account would shed light on
contexts and processes involved with depression patterns that are missed when analyses are
conducted with an aggregated sample. Qualitative thematic analyses of the mothers’ stories were
then employed to support the quantitative results.
Chapter five integrates results from both studies and discusses the relevance to the
literature on maternal depression, and contributions toward ecological and resilience
frameworks. Important to this chapter will be discussion and implications for practice, research
and policy.
Dissertation Sample
The sample for the dissertation is limited to mothers who participated in all three
waves of data collection (N = 223) in order to categorize mothers according to their depression
patterns (explained in the previous section). Table 1.1 provides demographic information about
this sample, with the demographic information distributed by depression pattern.

9

Table 1.1. Demographic Variables Characterized by Rural Mothers’ Depression Patterns
Low
n = 75
% (n)
31.2 (8.2)

Age
M (SD)
Education
High school &
less
More than high
school
Ethnicity
White
Hispanic/Latino
African
American
Other
Marital status
Single
Married
Living
w/partner
Divorced
Separated

Moderate
n = 25
% (n)
29.1 (6.8)

High
n = 14
% (n)
31.6 (7.4)

Improving
n = 48
% (n)
29.6 (7.0)

Worsening
n = 34
% (n)
30.2 (7.0)

H-L-H
n = 27
% (n)
32.6
(7.1)

30.6 (22)

9.7 (7)

6.9 (5)

26.4 (19)

16.7 (12)

9.7 (7)

34.0 (48)

12.1 (17)

5.7 (8)

19.9 (28)

15.6 (22)

12.8 (18)

30.7 (47)
40.6 (13)
33.3 (5)

10.5 (16)
12.5 (4)
26.7 (4)

7.8 (12)
0
0

20.9 (32)
21.9 (7)
26.7 (4)

16.3 (25)
15.6 (5)
6.7 (1)

13.7 (21)
9.4 (3)
6.7 (1)

40.0 (6)

0

6.7 (1)

33.3 (5)

20.0 (3)

0

31.5 (17)
39.0 (32)
22.9 (8)

11.1 (6)
7.3 (6)
17.1 (6)

7.4 (4)
4.9 (4)
5.7 (2)

20.4 (11)
23.2 (19)
34.3 (12)

16.7 (9)
12.2 (10)
14.3 (5)

13.0 (7)
13.4 (11)
5.7 (2)

31.0 (9)
33.3 (5)

13.8 (4)
13.3 (2)

6.9 (2)
6.7 (1)

17.2 (5)
6.7 (1)

17.2 (5)
33.3 (5)

13.8 (4)
6.7 (1)

For qualitative analyses, three cases from each depression pattern were selected (n = 18
cases total). In order to maximize understanding of the differences and nuances of each pattern,
extreme cases from each pattern were selected. Thus for each pattern, cases were selected based
on extreme depression score values. For example, mothers with consistently lowest depression
scores were selected for the low depression pattern. Likewise, mothers with the consistently
highest depression scores were selected for the high depression pattern. For the improving,
worsening and erratic patterns, mothers were selected for the extreme differences between
depression scores across all three waves, according to their pattern. In addition, where possible,

10

cases were selected from different states for each pattern to vary location. The worsening
depression pattern is the only pattern in which more than one case was from the same state.
Table 1.2 presents the sample for qualitative analyses and lists the states included in each pattern,
as well as mothers’ marital status, age and depression scores for all three waves.

Table 1.2. Sample for Each Depression Pattern
Depression
Pattern/State
Low
 MA
 NE
 OH

Pseudonym

Marital Status

Age

Depression Scores
Wave 1 Wave 2 Wave 3

Joelle
Reba
Jillian

Divorced
Married
Married

37
34
40

2
4
4

4
2
6

8
1
5

Moderate
 IN
 MI
 OH

Louanne
Tomasa
Becca

Single
Married
Married

22
32
23

23
24
16

21
16
14

19
20
15

High
 MD
 NH
 NY

Nan
Jade
Zola

Single
Divorced
Living with partner

42
33
45

48
42
34

42
56
52

45
38
41

Improving
 KY
 LA
 MN

Kami
Shakira
Gabby

Married/divorced
Separated
Divorced/married

35
47
38

51
34
53

13
15
3

3
7
2

Worsening
 MN
 MN
 NY

Trinity
Mercy
Soliel

Single
Single
Married

39
27
29

11
7
3

37
15
33

34
28
44

Erratic
Sancha
Single
26
37
12
43
 CA
Abiona
Single
34
26
11
46
 MD
Steph
Married
49
20
10
51
 NY
*Where two marital statuses are indicated, the first is status at wave one, the second indicates
change in status in wave two or three.
11

Rural Families Speak Findings Related To Depression
These studies use data from the Rural Families Speak project, a multidisciplinary, mixed
methods, longitudinal approach to developing an understanding of the challenges and
complexities faced by rural low-income families within the context of their communities (see
Bauer, 2004) Rural families struggle with limited employment opportunities and therefore
higher poverty rates, limited educational and training opportunities, and difficulty maintaining
dependable, affordable childcare and transportation (Bauer, Braun, & Dyk, 2003; and Findeis,
Henry, Hirschl, Lewis, Ortega-Sanchez, Peine, & Zimmerman, 2001). Many of the studies
stemming from the Rural Families Speak project have focused on factors related to the mental
health of rural mothers in the sample, with depression being one of the most used indicators of
maternal mental health. Though the studies are varied in design and methods, with some using a
single wave of data for analyses and others using longitudinal designs, common themes have
emerged in relation to maternal depression:
1). Participants’ perceptions of life satisfaction and confidence in parenting ability
(Bulock, 2004), and social support (Bulock, 2004, 2007; Islam, 2004; Garrison, Marks,
Lawrence & Braun, 2004; and Kim, Seiling, Stafford & Richards, 2005) are associated with
lower depression.
2). Food insecurity (Bulock, 2007; Olson, Anderson, Kiss, Lawrence, & Seiling, 2004;
and Olson, 2006), and perceived economic strain (Bulock, 2007; and Dolan, Richards, Sano,
Bauer, & Braun, 2005) are associated with higher depression.
3). Employment status, especially continued employment status over time, is related to
lower depression (Dolan, Richards, Sano, Bauer, & Braun, 2005; and Kim, Seiling, Stafford &
Richards, 2005).

12

4). The relationship between low income and depression is mediated by mothers’
perceived economic strain. That is, annual income was related to higher depression when
mothers perceived they were under economic strain (Bulock, 2007).
5). Stronger religious beliefs and faith community involvement is associated with lower
depression (Garrison, Marks, Lawrence & Braun, 2004).
All of the studies cited above employed statistical techniques that used aggregated means,
correlations, and covariances to develop quantitative analytical models of risk and protective
factors. However, the stories and voices of the individuals tend to become lost in those
aggregated data. The studies in this dissertation further pursue these data at the individual and
group level to explore patterns of change in depression over time in order to understand life
circumstances that may be associated with the differential depression patterns. Also, from a
resilience perspective, it would be useful to understand the underlying meanings and experiences
of these rural mothers, and why some of the mothers’ depressive symptoms improved, why some
worsened, and why some mothers’ symptom patterns were erratic. Therefore, another aim of
this dissertation was to gain an understanding of the context in which these patterns occur. To
that aim, a mixed method approach was utilized to include both qualitative and quantitative
analyses of rural mothers who participated in all three waves of data collection.
To date there are few studies that have tested longitudinal depression trajectories in
mothers (Smith & Howard, 2008; and Gross, Shaw, Burwell & Nagin, 2009). However, those
data were aggregated for quantitative, structural analyses only, such that individual change
patterns may have been missed. The studies in this dissertation present a unique contribution to
the literature in that they employ mixed methods approaches to explore those patterns both

13

qualitatively and quantitatively in order to gain a better understanding of the contextual forces
influencing mother and family well-being within a community sample.
Theoretical Frameworks
These studies employ the human ecological framework and resilience approach to
studying individuals and families. Within the context of these studies, the human ecological
approach provides a framework with which to view rural low-income individuals and family
members as they interact within family subsystems, and with surrounding sociocultural systems,
including work, health and social service agencies, and societal norms and expectations.
Individuals and families are viewed as dynamic and adaptive to changes in internal and external
environments with which they are interdependent (Bronfenbrenner, 1986). The ecological model
also provides a lens for examining broader system influences on individual and family functions
over time (Bubolz & Sontag, 1993). For instance, welfare reform and economic change, and
limited employment and educational opportunities, coupled with stricter policies regarding
employment and access to public assistance, can affect the extent to which workers are able to
provide for the economic needs of their families. This can contribute to parental stress and affect
mental health, which in turn, can affect family relationships and caregiving abilities.
Similar to the human ecological approach, the resilience approach focuses on adaptation
to changes or stressors, within the family environment and in response to external environmental
pressures. However, the resilience approach further provides a lens for viewing and
understanding the capacities and resources, as well as the shared meanings and internal processes
in which individuals and families engage in coping responses to stressors (Patterson, 2002). In
other words, the resilience approach helps to understand how individuals and families adapt.

14

Currently individual and family resilience are seen as two separate frameworks with
separate literature bases and lines of research, although family resilience researchers borrow
concepts and constructs from individual resilience research. Consequently, resilience is
inconsistently defined (Luthar, Cicchetti & Becker, 2000; Hawley & DeHaan, 1996; and
Patterson, 2002a, 2002b) and the links between the two are unclear. Family resilience is a
systems level theory, yet family systems are made up of individuals whose health, attitudes and
development contribute to whole system functioning. It is hypothesized in this dissertation that
adaptation and functioning (resilience) of rural working poor mothers contributes to adaptation
and functioning (resilience) of the whole family system.
While family has been conceptualized as both a risk and protective factor influencing
individual resilience (see several chapters of Luthar, 2003), less is known about the influence of
the individual on family resilience (Hawley & DeHaan, 1996). In addition, studies of individual
risk and resilience have focused on child and adolescent development (see several chapters of
Luthar, 2003; Felsman, 1989; Clark & Clark, 2000), or on adult outcomes of childhood and
adolescent risk experiences and resilience processes (Higgins, 1994; Rubin, 1996; Quinton,
Rutter & Liddle, 1984). In order to make a better link between the two theories, it is important to
understand how resilience takes shape within adults in families and how their resilience
influences family level development. Therefore, these studies aim to bring these two lines of
research together to begin building a more cohesive and comprehensive resilience framework.
Given the pivotal role mothers play in families, it makes sense to begin linking individual and
family resilience theories with a study of mothers and how their individual resilience relates to
family resilience in this sample of rural low-income women.

15

The study conducted by Conger and Conger (2002) of Midwestern adolescents and their
parents is an example of a study that brought the two lines of research together. Their research
focused on resilience at the level of individuals (adolescents), dyadic pairs (marriage
relationship, sibling subsystem, and the parent-child subsystem), and family. For their broad
application of the construct, they adapted the broad definition of resilience proposed by Luthar,
Cicchetti and Becker (2000) to conceptualize resilience at many levels: “Resilience refers to a
dynamic process encompassing positive adaptation within the context of significant adversity.”
(p. 543). The same definition is adopted for the present studies. In addition to being applicable
to resilience at multiple levels, this definition is important because it implies two conditions by
which an individual or family could be deemed resilient: first, there has been exposure to
significant adversity; and second, an achievement of positive adaptation, or competent
functioning and development has been reached, despite the exposure to risk (Luthar, Cicchetti &
Becker; Patterson, 2002a, 2002b; Hawley and DeHaan, 1996).

16

Research Questions and Hypotheses
The following research questions and hypotheses were posed in order to gain a better
understanding of the longitudinal patterns of depression among rural mothers, and how those
patterns are linked to risk and resilience processes in rural mothers and their families.
Table 1.3. Research Questions and Hypotheses of the Dissertation and Studies

Study 1

Research Questions
1. How can resilience at the
individual and family levels be
theoretically linked?

Hypotheses
1. Positive adaptation and functioning
(resilience) of mothers is related to
positive adaptation and functioning
(resilience) of the whole family system.

2. What accounts for depression
patterns among rural low-income
women?

Dissertation

2. Mothers with low, moderate and
improving depression patterns will
have fewer risk factors and more
protective factors than mothers with
high, worsening and erratic depression
patterns.

1. How is evidence of rural mothers’
resilience related to evidence of
resilience within their families?

Note: This study does not aim to test
specific hypotheses.

2. How do mothers’ perceptions,
social supports, risks and the other
contextual circumstances in rural
mothers’ lives differ when
comparing mothers in each of the six
depression categories?
Study 2

1. Can Bronfenbrenner’s PersonProcess-Context-Time model be
integrated with a resilience
framework to explore the
organization of risk and resilience
factors amid longitudinal depression
patterns?
2. How do risk and protective
factors organize themselves
empirically amid depression patterns
of low income rural mothers?

17

1. Mothers with low levels of
depression across all three years will
have fewer risk factors than mothers in
the other depression patterns.
2. Mothers whose depression was high
all three years, or whose depression
worsened over the course of the study,
will have more risk factors than
mothers in the other depression
patterns.

Table 1.3. (cont’d)
Study 2
(cont’d)

Research Questions
3. What circumstances or processes
in rural mothers’ lives are evident in
the qualitative data that are not
accounted for quantitatively to
explain variability in the
relationships between risk and
protective factors and depression
patterns?

Hypotheses
3. Food insecurity and a higher number
of health problems will be risk factors
for mothers in the high and worsening
depression patterns.
4. The relationship between monthly
income and depression will be
mediated by mothers’ perceptions of
economic strain for the whole sample.
5. The relationship between mothers’
sense of parental confidence and
depression will be mediated by
mothers’ perceptions of parental social
support for the whole sample.

18

CHAPTER 2
LITERATURE REVIEW
Introduction
By the year 2030 depression will rank second among the ten leading causes of death in
the world, and it is projected that it will rank first for high income countries, such as the United
States (Mathers & Loncar, 2006). Major depression is the leading cause of disability in the
United States (US Department of Health and Human Services, 1999), and it is twice as common
in women (Kessler et al., 2003), especially women of child-bearing ages (18-45 years old)
(Substance Abuse and Mental Health Services Administration, 2010). Mothers with young
children seem to be especially vulnerable to depression (Mistry, Stevens, Sareen, De Vogli &
Halfon, 2007; Zuckerman & Beardslee, 1987).
Women play an important role in the nurturing and development of family members and
the day-to-day management of family functioning. However, the capacity to carry out such roles
is limited when women experience depression. The child development literature alone has
produced numerous studies on the relationship between maternal depression and poor child
outcomes, such as poor child health (Casey, Goolsby, Berkowitz, Frank et. al, 2004), mental
health disorders (Hammen, 2009), child disruptive behaviors (Gross, Shaw, Burwell & Nagin,
2009; Turney, 2011; and Mustillo, Dorsey, Conover & Burns, 2011), and deficits in cognitive
performance and dysfunctions in emotional and behavioral regulation among infants and young
children (for a more extensive review see Hammen, 2003). The social sciences literature has
increasingly focused on the correlates and detrimental effects of depression in mothers, as well
as some of the processes by which maternal depression is related to family dynamics.

19

Most of the literature to date has examined maternal depression from a risk-only
perspective. Less is known about resilience processes in mothers with depression and their
families. Are there buffers that some mothers put in place to help them function during
depressive episodes so they can carry out their mothering role? Do some of those buffers
contribute to resilience processes within the families? Why do some mothers, under similar risk
circumstances, experience very low levels of depressive symptoms? Ecological and risk and
resilience lenses are needed in order to understand some of the factors and mechanisms that help
some mothers and their families function well in the face of depression. From an ecological
approach, individuals with depression and their families are dynamic and adaptive to changes
within their family and in response to changes in external systems (Bronfenbrenner, 1986). The
ecological model also provides a lens for examining contextual processes within families, and
broader system influences on individual and family functions over time (Bubolz & Sontag,
1993). A risk and resilience approach provides a lens for viewing and understanding the
capacities and resources of depressed individuals and their family, as well as the shared
meanings and internal processes in which individuals and families engage as coping responses to
depression related stressors (Patterson, 2002).
The overall purpose of these exploratory studies is two-fold: to explore the nature of rural
low-income mothers’ longitudinal depression patterns, and to build upon a risk and resilience
theoretical framework. Because of the importance of theory to research, it is important to begin
this review of the literature by providing the theoretical links between resilience and ecological
approaches in order to lay a foundation for a unified framework on risk and resilience. The
review will then provide a research backdrop for understanding what has been learned about
depression, especially the research on factors that are associated with depression among mothers.

20

In addition, a review of studies from the Rural Families Speak project that relate specifically to
depression among rural low-income families will be provided.
Ecological and Resilience Frameworks
These studies employ resilience and human ecological approaches to studying individuals
and families. Luthar, Cicchetti and Becker (2000) explain that much of the research on individual
resilience has been guided by three theoretical frameworks: a “triarchic framework” (p. 552),
ecological theory, and a structural-organizational framework. They also suggest that studies of
resilience should employ theoretical frameworks relevant to “the particular adversity
circumstance under study” (p. 553).
Therefore, a human ecological approach is connected to this review in two ways. First,
following the suggestion by Luthar, Cicchetti and Becker above, a human ecological approach
makes sense because it provides a contextual lens with which to view rural low-income
individuals and family members as they interact within family subsystems, and with surrounding
sociocultural exosystems, including extended family and friends, work, health and social service
agencies, and societal norms and expectations. The ecological model also provides a lens for
examining broader system influences on individual and family functions over time (Bubolz &
Sontag, 1993). For instance, welfare reform and economic change, and limited employment and
educational opportunities, coupled with stricter policies regarding employment and access to
public assistance, can affect the extent to which workers are able to provide for the economic
needs of their families. This can contribute to parental stress and affect mental health, which in
turn, can affect family relationships and caregiving abilities.
Second, to this date research on resilience is categorized into two broad areas: individual
resilience and family resilience. Family resilience has become a more widely used approach for

21

research and practice in family science over the past several decades, which has inspired much
discussion in the field. Some of the discussion centers on the relationship between family
resilience and resilience at the individual level. The two perspectives share much in common
including similar definitions of resilience, similar foci on identifying processes which lead to
competent outcomes, and agreement that resilience is intricately linked with development.
Despite the commonalities, the two have not commonly been employed in the same study.
Theoretical discussions have provided definitions and described resilience as a construct
and process (Hawley and DeHaan, 1996; Luthar, Cichetti and Becker, 2000; and Patterson,
2002a and 2002b; Ungar, 2010). More recent discussions connect a resilience theoretical
framework with an ecological perspective in terms of considering contextual influences, both
within the family and surrounding environments (e.g., see several chapters of Bevcar, 2013).
This review uses Bronfenbrenner’s Process-Person-Context-Time model (as discussed by Tudge,
Mokrova, Hatfield & Karnik, 2009) as a structure with which to begin building a unifying
resilience-ecological framework. The first step will be to tie resilience at the individual level
with the human ecological perspective set forth by Bronfenbrenner (Bronfenbrenner, 1986, 1989,
1994, and as discussed by Tudge, Mokrova, Hatfield & Karnik, 2009). Much of
Bronfenbrenner’s writing on human ecology placed the developing individual as the center of
focus. Thus it makes sense to connect Bronfenbrenner’s key concepts and processes with
concepts and processes discussed in the literature on individual resilience. Likewise, the
following step will tie family resilience with the family ecological framework proposed by
Bubolz and Sontag (1993). Table 1 below is a resilience concept matrix that places important
components and processes of all four frameworks together for visual comparisons.

22

Table 2.1. Ecological and Resilience Concept Matrix
Bronfenbrenner’s
Ecological
Framework

Concepts from
Individual Resilience

Bubolz & Sontag’s
Family Ecological
Framework

Concepts from
Family Resilience

Proximal processes

Risk factors and
Protective mechanisms
with which an
individual interacts
within the proximal
environment

Resource
management and
decision making of
the family in
response to normal
stress and adversity

Adjustment,
adaptation of a
family in response to
adversity

Person

Characteristics/
attributes of an
individual and
propensity for
adaptation to change
and adversity

Family

Capabilities,
resources, meanings
and beliefs of
families to respond
and adapt to change
and adversity

Context

Risk factors and
protective factors within
the environment or
situation

Environments

Significant risk
exposure and
protective factors
within proximal and
distal environments
which can affect a
family’s functioning

Time

Developmental
outcomes over time

The role of time

Family level
outcomes over time

Ecological And Resilience Processes At The Individual Level
This section will discuss key concepts and processes related to ecological influences on
mothers with depression, and how those influences are related to the process of resilience. As a
departure from most ecological discussions, but consistent with a life span development
approach, this section views the mother with depression as the developing individual of interest,
rather than the child. Bronfenbrenner’s Process-Person-Context-Time model (PPCT) (as
23

discussed by Tudge, Mokrova, Hatfield & Karnik, 2009) will provide the structure for this
discussion of ecological and resilience processes at the individual level.
Proximal processes. Proximal processes refer to the reciprocal, progressively complex
interactions between the developing individual and his or her immediate surroundings, which
include other people, material objects, and cultural or social symbols and meanings (Tudge,
Mokrova, Hatfield & Karnik, 2009). In order to have an effect on developmental outcomes, such
proximal processes must take place regularly over extended periods of time. The individual is
viewed as an active agent in these processes, and “it is by engaging in these activities and
interactions that individuals come to make sense of their world and understand their place in it”
(Tudge, Mokrova, Hatfield & Karnik, 2009, p. 200). This is the essence of the first proposition
set forth in Bronfenbrenner’s later theoretical formulations. His second proposition is
interrelated with the first and states that:
The form, power, content, and direction of the proximal processes effecting
development vary systematically as a joint function of the characteristics of the
developing person; of the environment—both immediate and more remote—in which the
processes are taking place; the nature of the developmental outcomes under
consideration; and the social continuities and changes occurring over time through the life
course and the historical period during which the person has lived. (Bronfenbrenner, as
cited in Tudge, Mokrova, Hatfield & Karnik, 2009, p. 200)
Proximal processes, therefore, is a key component to the developing person, as well as to
this ecological model. Proximal processes are key to two interrelated components of individual
resilience: risk factors and protective mechanisms. Before explaining these terms, it is important
to provide a definition of resilience at the individual level. According to Luthar, Cicchetti and

24

Becker (2000), resilience is a “dynamic process encompassing positive adaptation within the
context of significant adversity” (p. 543). The authors then explain that there are two criteria
which signify resilience processes. First, the individual must have experienced exposure to
significant adversity. Second, the individual has achieved positive adaptation, despite being
faced with the adversity.
Risk factors refer to adversities individuals experience which pose a threat to positive
development (Masten & Powell, 2003). Such risks may exist within the individual (e.g., low
birth weight, mental illness) or in the developing individual’s environment (e.g., poverty,
divorce, abuse, war). Conversely, protective mechanisms are factors and processes that protect
individuals from adversities. Protective factors also may exist within an individual (e.g., IQ) or
in the individual’s environment (e.g., parenting quality), but the emphasis in research is on
identifying the mechanisms by which protective factors ameliorate the effect of risk factors on
the developing individual. Statistically, researchers look beyond main effects to additive,
mediating and moderating effects of the protective factors (Masten & Powell, 2003).
As can be seen risk factors and protective mechanisms are proximal processes. They are
most likely to occur as an interaction between the developing individual and those risk factors
and protective mechanisms that exist within the individual and his or her immediate
environment. As an example, in relation to rural low-income mothers with depression, risk
factors may include a mother’s depressive symptoms and her perspective on life as risks that
exist within her and history of abuse and current unemployment as risk factors that exist in her
environment. Protective factors may include her sense of competence as a mother and the social
supports she has available. As an example of proximal processes, the mother actively taps into

25

sources of social support in her immediate environments that reinforce her in her parenting role,
which then alleviates some of the stress and strain created by her risk factors.
Person. Bronfenbrenner (1989) viewed the individual as an active agent with capacities
to interact with and change the environment, thereby contributing to his or her own development.
He identified three types of capacities, or characteristics, which he called demand, resource, and
force characteristics (Tudge, Mokrova, Hatfield & Karnik, 2009). Demand characteristics are
those that may immediately influence interactions with another person, such as physical
appearance, age, gender, or skin color. Resource characteristics include mental and emotional
resources (intelligence, skills, past experiences), and social and material resources (access to
material necessities, and educational or occupational resources). Force characteristics enable the
individual to be more interactive with environments, and include temperament, motivation and
persistence. Motivation is an important force characteristic an individual can tap to influence her
own development and change the environment.
Masten and Powell (2003) list several characteristics, or attributes, of the developing
individual that are congruent with the resource and force characteristics just described. Such
attributes include cognitive abilities, self-perceptions of competence or worth, temperament or
personality, self-regulation skills, and outlook on life. These characteristics are viewed by
resilience researchers as protective factors that “have the potential to counterbalance adversity in
an additive model of resilience in which assets outweigh risks” (Masten & Powell, 2003, p. 13).
Adaptation refers to a process in which individuals or systems learn to survive changes or harsh
conditions in their environments (White & Klein, 2008). According to a resilience
conceptualization, individuals are active agents in their resilience processes in the ways they
employ personal attributes as they interact with adversities.

26

The rural low-income mothers in this study are viewed as having characteristics or
attributes similar to those described in this section. Such characteristics enable them to actively
engage other resources within their environments, thereby influencing their own development or
adaptation in their roles as mother and influencing their environment (Tudge, Mokrova, Hatfield
& Karnik, 2009).
Context. Context refers to the four interrelating environments for which
Bronfenbrenner’s ecological model has been known since his earlier writings (1986, 1989, 1994,
and earlier), and include the microsystem, exosystem, mesosystem and macrosystem. Most of
the development and proximal processes discussed previously take place within the
microsystems with which rural low-income mothers interact on a regular basis. Contextual
attributes involve close relationships and relational patterns within the microsystems which are
likely to influence rural mothers’ resilience processes, and include relationships with her spouse
or partner, with her children, and connections with peers at work and other extended family
members and social networks.
Mesosystems refer to interactions between differing microsystems, or between other
systems in the model. Exosystems are those systems which have an indirect influence on the
individual. Examples of exosystem effects on a rural low-income mother’s resilience processes
include the school system, which may or may not provide specialized services for her children,
or local social service agencies which decide whether she qualifies for food stamps this month.
Finally, macrosystems encompass the cultural or subcultural value systems, belief
systems, laws, resources, and opportunity structures, or structural barriers (Tudge, Mokrova,
Hatfield & Karnik, 2009). According to these authors, in order for any value system or other
component of the macrosystem to influence a developing individual, it must be experienced

27

within the proximal processes of the microsystems in which the person is situated. Cultural
values and structural supports are very important to resilience processes for ethnic and minority
populations. Ungar (2010) suggests that researchers and practitioners place culture and context
as more important to resilience processes than individual factors, such as cognitive style or
temperament. Examples of macrosystem effects on rural mothers’ resilience processes include
religious and cultural beliefs, financial supports for farm owners, welfare reform regulations, and
disability determination regulations.
Time. Time influences individual development, and according to Tudge and colleagues
(2009), Bronfenbrenner conceptualized the influence of time as consisting of three subfactors.
The first two, micro-time and meso-time, are concerned with events and activities interacting
with the individual’s development trajectory. Consistent with its name, micro-time is concerned
with specific activity that directly involves the developing person (e.g., history of abuse,
marriage, birth of children, divorce). Meso-time is concerned with activities in the individual’s
environment that occur with some consistency (e.g., work schedules, school schedules,
appointments with social service agencies, community or family celebrations). Finally, macrotime refers to the chronosystem, which is concerned with historical events occurring during the
individual’s life time that can have an influence on development (e.g., economic recession, war,
natural disasters). For resilience processes, researchers and practitioners are concerned with
developmental outcomes as measured at any point in the developing individual’s lifetime.
Consistent with a process conceptualization, outcomes may differ at any given time during a
person’s development (Masten & Powell, 2003), such that a young rural mother may be adapting
positively in early motherhood, but negatively a few years later when her children become

28

teenagers. Each of the examples provided for time subfactors can influence resilience processes
for rural low-income women, depending on when outcomes are measured.
Ecological and Resilience Processes at the Family Level
Similar to the previous section, this section will discuss key concepts and processes
related to ecological influences on the family. Family ecological concepts will be connected
with related concepts from family resilience, with a focus on applying processes to rural lowincome families in which the mother experiences depression. Concepts from Bubolz and Sontag
(1993) to be considered include resource management, decision making, adaptation, family,
environments, and the role of time. The first three concepts can be conceptualized as akin to
proximal processes (Bronfenbrenner, as discussed in Tudge, Mokrova, Hatfield & Karnik, 2009);
however, the proximal processes discussed in this section are concerned with family level
relational patterns and processes that influence family level outcomes.
Proximal processes - Resource management. When Bubolz and Sontag conceptualized
family ecology theory in their seminal work (1993), one of their main goals was to emphasize
resource management in families “for creative adaptation, human development, and
sustainability of environments” (p. 419). They defined management as “a comprehensive
process involving the attainment, creation, coordination, and use of resources for meeting goals
and realizing values” (p. 436). As a comprehensive process, it encompasses several interrelated
goal-oriented processes, including problem solving, decision making, goal setting, planning,
implementing and evaluating, as well as learning, motivating, mediating, and integrating.
Though resource management is rarely discussed in the literature on family resilience, the
connection is implied. One purpose of this discussion is to make that connection more implicit.

29

First, a definition of family resilience is in order to establish a context for the connection. Using
Hawley and DeHaan’s definition (1996), family resilience refers to
“The path a family follows as it adapts and prospers in the face of stress, both in
the present and over time. Resilient families respond positively to these
conditions in unique ways, depending on the context, developmental level, the
interactive combination of risk and protective factors, and the family’s shared
outlook. (p. 65)

Two family stress and coping theoretical models discussed in the family resilience
literature—The Double ABCX Model (McCubbin & Patterson, 1983) and the (FAAR) Family
Adjustment and Adaptation Response Model (Patterson, 2002a, 2002b)—mention the existence
of resources families possess or tap into in order to mediate the stresses they face, however they
do not explore the ways in which families gather, manage and employ those resources.
Consideration of these processes within theoretical models has implications for conceptualizing
the family’s role in resilience processes as more active, intentional, and goal-oriented.
Resource management processes can be further connected with two other family
resilience processes, adjustment and adaptation. According to Patterson (2002a, 2002b),
adjustment entails the process by which families balance normal life demands with existing
capabilities. Conversely, adaptation is the process by which families restore balance (during or
after a crisis) by reducing demands, increasing capabilities, and/or changing meanings
(Patterson, 2002a, 2002b). In Patterson’s FAAR model, demands are conceptualized as
normative and nonnormative demands, strains, and hassles. Capabilities are conceptualized as
“tangible psycho-social resources and coping behaviors,” (Patterson, 2002b, p. 236). In terms of

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family ecology, capabilities can be viewed as resources which need to be activated, managed or
acquired to ensure positive adjustment or adaptation.
In relation to rural low-income families, resource management may entail the processes
by which families budget their money so they can pay their bills, or harness their level of
motivation to invest in the human capital of a family member, such as college or training
programs to qualify for a better paying job.
Proximal processes – Decision Making. Decision making processes, according to
Bubolz and Sontag (1993), involve: 1) recognizing a decision needs to be made; 2) identifying
and comparing alternatives; and 3) choosing an alternative. Decision making is a complex
process because there are times when decisions must be made under conditions of uncertainty,
and can involve (but not always) multiple members of the family.
Similar to the discussion above, the resilience models reviewed do not include decision
making processes explicitly; however, the concept can be connected in much the same way
resource management processes can be connected. As normative, nonnormative stresses or
crises arise, adjustment and adaptation mechanisms involve identifying that a problem needs to
be solved, and that a decision needs to be made (even ignoring a stressor is a decision). Families
must decide which resources and coping behaviors to employ in order to off-set the demand.
Consistent with resilience processes, it makes sense that resource management and
decision making processes are carried out in interaction with family meanings. Patterson (2002a,
2002b) discusses three levels of family meanings: 1) a family’s appraisal of the demands that are
presented, and their appraisal of their capabilities (resources); 2) their identity as a family; and 3)
their world view.

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Connecting these concepts and processes to the population of interest, rural low-income
families employ decision making processes if they need to decide which medications they can
afford to buy or which bills they can afford to pay. They also make decisions about which
sources of social support will be helpful, such as a relative, close friend, or a social service
agency. There are many types of decisions, suggesting that this would be a fruitful area of
research in connection with resilience processes.
The concept of family in relation to family ecology and family resilience. Through
the family ecological lens presented by Bubolz and Sontag (1993), the family is viewed as
interactive and interdependent with the larger environment. However it is important to recognize
that families bring certain characteristics to the interdependent relationship with the environment
that influence the nature of the interactions that take place. Family characteristics are also
important to resilience processes. However, it is important to begin a discussion of family
characteristics with a conceptualization of family because agreement on a definition of the term
has been difficult to achieve in the family science field (Arcus, Schvaneveldt & Moss, 1993;
Duncan & Goddard, 2005).
The term family was conceptualized by Bubolz and Sontag (1993) to be inclusive because
of the variety of family structures that exist in our culture. According to these authors, families
are “composed not only of persons related by blood, marriage, or adoption, but also sets of
interdependent but independent persons who share some common goals, resources, and a
commitment to each other over time” (p. 435). An important point these authors make is that
families themselves must determine who is a part of their family.
This conceptualization speaks to the first family characteristic to be briefly addressed:
structure. Family structures have become diverse and complex (e.g., two-parents, single-parent,

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childless couples, step-families, families with same-sex parents, cohabitating couples with
children, grandparents raising grandchildren), especially with the rise in divorce and remarriage.
The important point is that families need to define for themselves their family boundaries, and
determine who is in and who is outside of the family.
The second characteristic is ethnic or national origin. Through their ethnicity, families
present physical characteristics, as well as values and beliefs to their interactions with other
environments. The third characteristic is life stage. Consistent with a family life course
developmental framework (White & Klein, 2008), the family ecological perspective is concerned
with change and development within families and among the individuals in them. The final
characteristic is socioeconomic status, which influences how families see themselves, how they
interact with the world, and how they access resources.
As Bubolz and Sontag (1993) point out, “families, regardless of their particular
structure…ethnic or national origin, life stage, or socioeconomic status, transform matter—
energy and information and engage in adaptation” (p. 438). According to Patterson’s Family
Adjustment and Adaptation Response (FAAR) Model (2002a, 2002b), families bring these
resources to resilience processes in the shape of capabilities, resources, and meanings and beliefs
in order to counterbalance the stresses and adversities they face.
Family environmental context. Context at the family level refers to the interrelated
environments described by Bubolz and Sontag (1993) in which family is at the center and is
shown to be interdependent with each environment. The natural physical-biological
environment consists of the resources of this world as they exist unaltered in nature. This
environment is important for human survival and sustenance. However, it is also important
because it provides a backdrop for the spaces humans create in which they live and play. As the

33

authors point out, “people develop emotional attachments to their environments” (p. 433).
Within the natural physical-biological environment, many families escape from the daily
pressures of life to spend time together, through family vacations to the mountains, or a day
fishing at a local pond. Rituals and stories experienced in this environment help families create
meaning. Such meanings create a sense of unity and family identity, a type of armor families don
to get through rough times. Family meanings are important to the resilience process because they
can help shape a family’s mindset as they balance the demands imposed by crisis events
(Patterson, 2002a, 2002b).
The natural physical-biological environment also can impose risks, as is the case when
natural disasters strike. Such occurrences can cause significant risks or crises for families, as
homes, properties, or even whole cities can be destroyed, as we saw in the cases of hurricane
Katrina in New Orleans, hurricane Sandy along the Atlantic coast, and the earth quake and
ensuing tsunami in Sendai, Japan. Disasters like those just described can pose increased risk for
rural low income families, who may have limited resources available to them. However,
resilience processes are activated when families learn to cope and adapt to the circumstances.
The human built environment consists of “alterations and transformations made by
humans of the natural physical-biological environment” (Bubolz & Sontag, 1993, p. 432). In
other words, it is the result of humans interacting with the natural physical-biological
environment. The adaptations humans make by building homes, towns, roads, farm lands, and
other structures are protective factors that are necessary for survival and sustenance. However,
there are risk factors that also have been created by humans as a result of these adaptive
processes. Polluted air, water, and soil are byproducts of these interactions, and they pose risks,
not only to humans, but also to the natural physical-biological environment. Other risks can

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include the decay of homes and other buildings, fires caused by unsafe practices, or traffic
accidents caused when humans travel. These and many other risks can cause harm to humans
and the natural environment. Family resilience processes are evident when these human built
disasters occur.
The social-cultural environment (Bubolz & Sontag, 1993) is more abstract, but is
important to family resilience processes as it includes relationships, patterns of interacting,
values, and beliefs and norms. It also includes social structures, such as institutions, community
groups, governments, economies, laws and languages. It is within this environment that many
stressors and crises become visible as families adapt to changes in economies, downsizing of
workplaces, or changes in laws. With limited resources, rural low income families are at
increased risk when there are changes in laws (e.g., welfare reforms regulations) or when there
are limited resources available, such as employers or health care providers. Protective factors for
these families, such as social service agencies and local food pantries, become important
resources for rural family resilience processes.
The role of time. Like the development of individuals, family development also occurs
within the context of time. “The cyclical, recurring, and sequential nature of events in the family
ecosystem and changes and adaptations over time are of special interest in an ecological
perspective” (Bubolz & Sontag, 1993, p. 430). For resilience processes, time is needed for
families to respond to risks, engage in protective processes, and adapt to nonnormative demands
at the same time they must accommodate normative life demands (Patterson, 2002a). In
addition, it is important to consider the interactive nature of time and family life when thinking
about family level outcomes of resilience processes. Similar to resilience at the individual level,
outcomes of family resilience processes can differ depending on the point at which outcomes are

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assessed. For example, a young family who loses a mother to cancer may not function
competently in the first year after the mother’s death; however, over time the young family may
recover from the crisis to function competently.
In determining criteria for competent functioning for family level outcomes, Patterson
refers to Ooms’ model of the four core functions of the family to meet individual, family and
societal needs (as discussed in 2002a, 2002b), and those include: nurturance and socialization;
family formation and membership; economic support, and protection of vulnerable members.
Patterson suggests that one way to conceptualize family level outcomes of a resilience process is
to consider whether a family fulfills one or more of these core functions. For rural low-income
families in which the mother experiences depression, a researcher or practitioner might consider
whether the family is healthy (nurturance and socialization) or whether the parents can provide
for basic needs of food, shelter and clothing (economic support).
Summary
This section has provided a comparative discussion of relationships between two
ecological models and resilience conceptualizations at the individual and family levels. The
purpose of this discussion was to provide a framework for the current studies of rural low income
mothers and their families in relation to the influence of longitudinal depression patterns on
mothers’ resilience processes and on the resilience processes of their families.
Because of the importance of depression to the lives of rural mothers and their families,
and because of its application to the theoretical framework put forth in this chapter, it is
important to understand the nature of depression and its far reaching consequences. Therefore,
the following section of this literature review provides a broad overview of depression.

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Depression
Depression is a disease that can have harmful consequences for individuals and their
families. Depression can be characterized by a constellation of behaviors and symptoms that
affect physical abilities (e.g., psychomotor agitation or retardation, fatigue, decreased appetite,
weight loss, insomnia or hypersomnia), emotions (e.g., feelings of guilt or worthlessness), and
cognitive abilities (e.g., difficulty with memory or concentration, suicidal thoughts) (Gotlib &
Joormann, 2010). According to Gotlib and Joormann, “depression is primarily a disorder of
emotion dysregulation and sustained negative affect” (p. 287).
Hammen (2009) describes depression as a complex construct to measure as it “varies in
chronicity, severity, and impairment” (p. 277). Further highlighting the complexity of
depression as a construct, Boland and Keller (2009) describe the episodic and chronic nature of
depression. For instance, longitudinal studies must carefully consider key points at which
change occurs in a depressive course. Key change points defined by the authors include episode,
remission, response, relapse, and recurrence. They further state that when considering the
recurring course of depression and its subtypes, it is more useful to think of depression as
dimensional rather than categorical (i.e. chronic major depressive disorder, dysthymic disorder,
double depression, or major depressive disorder) because the distinctions between subtypes are
clinically ambiguous.
In addition to the aforementioned difficulties in specifying course and subtypes,
psychological research also has revealed other heterogeneous aspects of depression, such as
genetic and neurobiological aspects, and cognitive and interpersonal aspects (see Gotlib &
Hammen, 2009; and Joiner, Brown & Kistner, 2006). These aspects of depression are
conceptualized in the psychological literature as vulnerabilities that interact with environmental

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or situational stressors, leading to a depressive episode. That is, while the presence of one or
more vulnerabilities may lead to depression in someone’s lifetime, it is more likely to lead to
depression when a stressful environmental or situational stressor occurs. For example, research
has identified genetic tendencies toward the development of depression in families; however the
risks increase in the face of traumatic experience such as a death of a close family member or
physical and sexual abuse or emotional neglect (Levinson, 2009).
In this section several research areas of depression, as mentioned above, will be described
broadly. While it is beyond the scope of this dissertation to hypothesize about a relationship
between the genetic and neurobiological vulnerabilities of depression and depression among this
community-based sample of rural low-income women in these studies, it is useful to provide a
general discussion of these two aspects in order to contribute to a comprehensive understanding
of the heterogeneous and complex nature of depression. The cognitive, social, and
developmental vulnerabilities of depression also will be discussed; however these vulnerabilities
are seen as informative to the conceptualization of depression in the present studies. It should be
noted that the research summarized in this section is based on clinical samples of depressed
patients. However the results of those studies are informative to an understanding of depression
that can be applied to research on depressive symptoms within community-based samples.

Genetic Vulnerabilities
An important line of research on genetic vulnerabilities involves family and twin studies.
In a meta-analysis of several family adoption and twin studies, Sullivan, Neale, and Kendler
(2000) found that heritability of major depression in general is likely to range from 31 to 42
percent. Genetic vulnerability increases substantially when three factors are considered for

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major depressive disorder (MDD): recurrence, age of onset, and severity (number of MDD
symptoms) (Levinson, 2009). In their meta-analysis, Sullivan, Neale, and Kendler (2000) found
that recurrence of MDD consistently predicted genetic vulnerability. There have been mixed
findings in regard to the predictive validity of age of onset. According to Levinson (2009),
among people with MDD, the risk of heritability increases the younger the person is at the onset
of the first episode of depression. The risk for genetic vulnerability decreases when age of onset
is above the age of 40. Some studies suggest that vulnerability increases further when there is
both recurrence and early age of onset (Levinson, et. al., 2003).
Neurobiological Vulnerabilities
Two distinctive, yet closely related lines of research have emerged that provide insight to
the ways depression influences various functions in the brain. The first line of research to be
discussed focuses on the dysfunctions that develop in the central nervous system and other brain
systems in response to stress. The second line of research focuses on some of the physical
structures of the brain and their roles in emotion and emotion regulation.
Numerous studies over the past several decades have been important for informing
scientists and clinicians about some of the neurobiological aspects of depression. The first line
of research to be discussed provides details on the highly complex ways in which hormones,
neurotransmitters and brain systems develop dysfunctional adaptations to stress. This is
important because the brain systems affected are responsible for the regulation of mood,
cognition, and behaviors related to appetite (Thase, 2009). This review will not provide a
detailed discussion of each brain system and their respective relationships with neurotransmitters
and hormones, however it is important to highlight particular brain systems and note how their
response to stress relates to the manifestation of depression symptoms.

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Studies have shown that the noradrenergic systems in the brain play a role in the
experience of stress, particularly the perception of threatening stimuli (Thase, 2009). According
to Thase, sustained response to stress is associated in the noradrenergic system with learned
helplessness in both animals and humans. Learned helplessness in humans involves a perception
that desired outcomes are highly unlikely, or conversely, that negative outcomes are very
probable. The individual exhibiting learned helplessness has the expectation that he or she is
powerless to change the outcome (Abramson, Seligman, & Teasdale, 1978); depression is likely
to result.
The serotoninergic systems have been shown to be responsible for several bodily
functions, such as appetite, the regulation of circadian rhythms, social and goal directed
behaviors, and impulsivity and aggression among humans and animals. In humans, these
systems also have been associated with suicidal and violent behaviors (Thase, 2009). In his
review, Thase (2009) explained that the serotoninergic systems are partly under genetic control.
Research in this area has revealed that individuals with one or two copies of the S allele (a
genetic code associated with the serotoninergic systems) are genetically vulnerable to the
development of depression (Firk & Markus, 2007; Thase, 2009). According to Firk and Markus
(2007), otherwise healthy individuals who have this genetic marker may have a reduced capacity
to develop coping mechanisms in response to stress, particularly acute or prolonged stressful
situations. Interestingly, this vulnerability to depression has been shown to be influenced by
social support (Firk & Markus, 2007). That is, in studies of maltreated children with this genetic
marker, those with good social support reported only slightly higher depression scores.
However, maltreated children with this genetic marker who did not have good social support
reported significantly higher levels of depression.

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The dopaminergic systems have been implicated in learned helplessness and social
defeat. Similar to the previous two systems reviewed, the dopaminergic systems develop
dysfunctional adaptations when an individual experiences chronic stress and these adaptations
result in behavior changes that are associated with depression.
Taken together, it is apparent that the brain systems described above are associated with
various mechanisms involving hormonal secretions, neurotransmitters, and interrelated brain
structures that are important for regulating mood and cognition, responses to stress, quality of
sleep, appetite, and violent and aggressive behaviors associated with suicidal thoughts and
tendencies. In addition, there is evidence that genetics and genetic-environment interactions
relative to these brain systems play a role in the level of risk for developing depression and other
mood disorders.
The second line of research to be discussed emerges from affective neuroscience, and
focuses on the structures of the brain responsible for emotion and emotion regulation, including
dysfunctional circuitry associated with depression. Four structures to be discussed in this section
include the prefrontal cortex (PFC), the anterior cingulate cortex (ACC), the hippocampus, and
the amygdala.
As a whole the prefrontal cortex is responsible for maintaining the representation of goals
and the means by which to achieve goals (Davidson, Pizzagalli & Nitschke, 2009) and is related
to instant versus delayed gratification in goal-directed behaviors. Research on the prefrontal
cortex (PFC) has identified that right-sided regions in particular seem important for maintaining
goals requiring delayed gratification (Davidson, Pizzagalli & Nitschke, 2009). These authors
also suggest that depressed individuals who exhibit hypoactivation of certain PFC regions may
be deficient in instigating goal-directed behavior, and in overriding automatic negative affective

41

responses and dysfunctional attitudes. These responses are also important in situations involving
reward and punishment. For example, in laboratory experiments, individuals with depression
showed a response bias toward punishment, whereas non-depressed individuals showed a
response bias toward rewards (Henriques & Davidson, 2000; Davidson, Pizzagalli & Nitschke,
2009).
Further research using imaging technologies reveals that individuals with depression
exhibit deactivation in several areas of the prefrontal cortex (Davidson, Pizzagalli & Nitschke,
2009). Deactivation also has been shown to be associated with a reduced volume of gray matter.
Davidson, Pizzagalli and Nitschke (2009) reviewed several studies that confirmed the association
between depression and reduction in the size and volume of several regions of the PFC and
found that the incidence is higher among patients with unipolar and bipolar depression who also
had a family history of mood disorder. Thus it appears that there is a genetic component to the
relationship between depression and PFC size and volume. Interestingly and very importantly,
there is evidence in research involving postmortem brains of patients with mood disorders that
reduction in PFC size and volume may actually be associated with cell atrophy rather than cell
loss (Rajkowska, 2000).
The anterior cingulate cortex (ACC) is hypothesized to function as a bridge between
attention and emotion, is critical for self-regulation and adaptability, and is also critical in
selective attention (i.e., prioritizing information), affect, and specific social behaviors (Davidson,
Pizzagalli & Nitschke, 2009). Davidson and colleagues (2009) describe two subdivisions within
the ACC: affective subdivisions and cognitive subdivisions. Affective subdivisions regulate the
body’s physical responses to stressful behavior and emotional events, emotional expression, and
social behavior. Cognitive subdivisions are associated with response selection and processing

42

cognitively demanding information. According to Davidson, Pizzagalli and Nitschke (2009), the
cognitive subdivisions of the anterior cingulate cortex monitors communication, or cross-talk,
between different regions of the brain, such that activation in this area of the brain further
activates other areas. It appears that this may be a mechanism for effortful control, that is,
emotion regulation in the face of competing demands or conflict. There is evidence that
activation of the cognitive subdivision can occur in order to trigger effortful emotional control,
for instance, in situations where an individual is failing to achieve a desired outcome or in the
presence of reward or punishment (Davidson, Pizzagalli and Nitschke, 2009; Bush, Luu &
Posner, 2000). According to Etkin, Egner, and Kalisch (2011) the dorsal ACC and the medial
prefrontal cortex work together during emotional conflict regulation processes, such as
reappraisal. For instance, in a conflict situation, there is an initial negative emotional appraisal
process and a reappraisal process where an additional positive appraisal is created to off-set or
compete with the original negative appraisal.
Among studies using various imaging and EEG technologies, it has been found that
behavior impairments in patients with major depression is associated with exaggerated automatic
detection of unfavorable performance outcomes and inability to recruit cognitive control after
committing an error (Davidson, Pizzagalli and Nitschke, 2009). These authors also describe
reduction in gray matter volume in areas that border the ACC.
The hippocampus is the third structure of the brain discussed by Davidson, Pizzagalli and
Nitschke (2009). The hippocampus is critical to episodic, declarative, contextual, and spatial
learning and memory. Studies using magnetic resonance imaging reveal atrophy of the
hippocampus in patients with major depressive disorder and borderline personality disorder
(Davidson, Pizzagalli, & Nitschke, 2009). It appears that older age, severity of depressive

43

symptoms, and length of recurring episodes may moderate atrophy. The aforementioned authors
also describe twin studies that suggest a gene-environment interaction. That is, volume
reduction in the hippocampus was only shown in the twin that was at risk for depression and
anxiety, compared to the other twin. It is important to note that there is some evidence (based
predominantly on animal studies) that regeneration of the hippocampus can occur in response to
antidepressant medications, electroconvulsive shock, or, most interestingly, as a consequence of
positive handling, learning, and exposure to enriched environments. This finding in particular
has implications for treatment, education, and support for individuals with depression.
The amygdala is the last structure of the brain to be discussed in this section. The
amygdala plays an important role in negative affect, and is critical for coordinating cortisol
arousal and attention for negative bias in the face of ambiguity (Davidson, Pizzagalli, &
Nitschke, 2009). According to these authors, in experiments where emotion was downregulated, there was a decrease in amygdala activation and increase activation in an area of the
prefrontal cortex, which is indicative of good emotion regulation.
According to the review conducted by Davidson, Pizzagalli and Nitschke (2009), there is
an association between an increase in amygdala volume and depression. In particular there is an
asymmetry that occurs in patients with major depression such that the right side of the amygdala
is smaller than the left side. In addition it has been shown that an increase in amygdala activity
is associated with bipolar and anxiety disorders.
It is apparent from the discussion of the second line of research stemming from affective
neuroscience that the four structures of the brain just described represent complex functioning
within and between these structures. Their relationships with depression reflect dysfunctions in
goal directed behaviors, especially those related to instant versus delayed gratification, regulation

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of negative affective responses, emotional and cognitive control in relation to sensitivity to error
detection, and a bias toward negativity when faced with ambiguity. In addition, depression has
been shown to be associated with decrease in size and volume of areas of the prefrontal cortex,
and the anterior cingulate cortex, as well as atrophy of the hippocampus and asymmetry in the
size of the amygdala. Further, similar to other neurobiological vulnerabilities discussed, there is
evidence for genetic components related to these structures that place individuals at risk for
depression, particularly when the individual is exposed to environmental stressors, such as
maltreatment or traumatic experiences.
Cognitive Vulnerabilities
Cognitive theories of depression propose that the way people think about, interpret,
explain, and develop attitudes to events in their lives determines their emotional responses.
When people develop negative cognitions about the events in their lives, they are said to be
vulnerable to depression (Abramson & Alloy, 2006; Joormann, 2009). Over the past several
decades, two models have been influential in conceptualizing depression in the psychological
literature: the hopelessness model (Abramson & Alloy, 2006; Alloy, Abramson & Francis,
1999); and Beck’s schema theory of depression (as discussed in Abramson & Alloy, 2006; and
Joormann, 2009). In addition, more recent mechanisms have been proposed that are important
for understanding the relationships between negatively biased cognitive processes and emotion
dysregulation that is characteristic of depression.
The hopelessness model of depression is a revision of Seligman’s concept of learned
helplessness (Abramson, Seligman, & Teasdale, 1978). Seligman developed the learned
helplessness concept while conducting experiments with animals and humans. He discovered
that learned helplessness develops when an organism learns that expected outcomes are

45

uncontrollable regardless of the organism’s attempts. In response to the uncontrollable outcomes
the organism develops motivational, cognitive and emotional deficits (Maier & Seligman, 1976).
Abramson and colleagues refined Seligman’s theory and proposed that hopelessness
occurs (in humans) when an individual holds an expectation that desired outcomes are highly
unlikely, or negative outcomes are very probable. The individual exhibiting hopelessness has the
expectation that he or she is powerless to change the outcome, and hopelessness depression (a
subtype of depression) is likely to result (Abramson, Metalsky & Alloy, 1989). They describe
their model as a causal chain in which hopelessness is preceded by more distal causes, beginning
with the perceived occurrence of a negative life event.
The occurrence of a negative life event, by itself, does not always lead to hopelessness
and depression. Rather, there are three possible causal inferences the individual can make about
the life event that can lead to hopelessness and hopelessness depression:
1. The individual might attribute the negative life event to stable and global causes (i.e.,
likely to last a long time and likely to affect many areas of life). This can lead to
hopelessness if the individual attaches a high degree of importance to the event.
2. The individual might infer negative consequences about the negative life event. The
attributed importance of the negative consequence and the perception that the
consequence will likely affect many areas of life is likely to lead to hopelessness. In the
present studies, a single rural low-income mother losing her job could be seen as a
negative event with important consequences that will likely affect many areas of her life.
3. Given the negative life event, an individual might infer negative characteristics about his
or her self. Examples of negative self inferences could include inferences about one’s
worth, personality, abilities, or desirability. If the person feels the inferred

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characteristics are not likely to change, and will affect outcomes in many areas of life, the
likelihood of developing hopelessness increases.
Further, the authors propose a diathesis-stress component as a more distal cause of
hopelessness and hopelessness depression. Depressogenic attributional style refers to a general
tendency some people have to attribute negative events to stable, global factors, especially when
those negative events occur within a particular domain of life (e.g., interpersonal relationships).
Thus the depressogenic attributional style (diathesis) is a distal contributing cause “of the
symptoms of hopelessness that operates in the presence, but not in the absence, of negative life
events (the stress)” (Abramson, Metalsky & Alloy, 1989, p. 362).
Similar to, but distinctive from hopelessness theory is Beck’s schema theory of
depression (as discussed in Joormann, 2009). According to this theory, individuals filter stimuli
from the environment through schemas (existing memory representations). The way information
is filtered directs individuals’ attention toward information that is congruent with their schema.
Negative schemas of depressed people can include themes of loss, separation, failure, rejection,
or abandonment. Thus there is a systematic bias in the way such individuals process information
relative to these themes. These negatively biased schemas are triggered by stressors, and then
negative thought processes about the self, the future, and the world dominate. Further, depressed
people select their attention toward stimuli in their environment in a way that is congruent with
their schema. These schemas are said to endure beyond depressive episodes, representing a
stable vulnerability. The schemas can remain latent, but when activated by a stressor, “schemainfluenced negative thoughts and processing biases initiate and maintain depressed mood
through a vicious cycle of increasingly negative thinking and negative affect” (Joormann, 2009,
p. 300). These automatic negative thoughts, generated by negative cognitive processes, revolve

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around pessimistic views about the self, the world, and the future. Cognitive theorists call this
the cognitive triad (Gotlib & Joormann, 2010). Individuals with negative schemas (or automatic
negative thought processes) that endure beyond depressive episodes are said to have
dysfunctional attitudes.
Since the formulation of these two cognitive models, researchers have had mixed results
with confirming their viability, particularly in attempting to gain further understanding between
negative cognitive thought processes and sustained negative affect that is characteristic of major
depression (see Gotlib & Joorman for a more extensive review). Studies have since suggested
that depressed people do not direct their attention to negative information per se; however they
do seem to have difficulty disengaging from it (Joorman, 2009; Gotlib & Joormann, 2010).
Further studies indicate that depressed people exhibit dysfunctional cognitive inhibitory control
over information kept in working memory. In healthy individuals, cognitive inhibitory control is
a mechanism used to balance the maintenance and manipulation of information in working
memory, for the purpose of controlling attention (Gotlib & Joormann, 2010). That is, executive
processes must constantly update material in working memory that is relevant to the current
context. Material that is relevant to the current context is allowed access to working memory by
executive controls, while material that is no longer relevant is discarded from working memory.
Depressed individuals, on the other hand, exhibit impairment in the ability to control the
processing of emotional material, and specifically have difficulty discarding irrelevant material
from working memory. Thus there is evidence that depressed people have trouble inhibiting, or
controlling, mood-congruent material, which could result in prolonged processing of negative,
irrelevant material, leading to sustained negative affect (Joormann, 2009; Gotlib & Joorman,
2010). Gotlib and Joormann (2010) further explain that the aforementioned process sets the

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stage for ruminative thinking. That is, they are prone to elaborating on negative material and
have difficulty stopping or inhibiting their attention and thought processes away from it.
The information in this section on cognitive vulnerability to depression lays a foundation
for understanding how depression may be played out in the lives of the rural low-income women
in the present studies. As indicated above, initial perceptions of negative life events and
stressors could play a key role in how those life events may affect their depression levels, as well
as their ability to function in their family roles. Perceptions and cognitive processes that persist
over time may influence their longitudinal depression patterns. Although experimental
interventions typically used in psychological research were not utilized for the present studies,
longitudinal mixed methods investigations may shed light on how cognitive and emotional
mechanisms characteristic of depression influence individual and family functioning.
Interpersonal Vulnerabilities
Theories of interpersonal vulnerability to depression have centered on the close
relationship between environmental (stressor events) and interpersonal attributes (e.g.,
dysfunctional relationships and early attachment experiences) that may play a role in the
development of depressogenic cognitions (Hammen, 2006; Hammen, Burge, Daley, Davila,
Paley & Rudolph, 1995). This perspective is informed by Bowlby’s theory of attachment, which
posits that humans need to maintain a relatedness with others for survival. More specifically,
attachment is a developmental process “directed at a specific partner…who can be relied on for
protection and comfort” (Bell, 2009). Attachment experiences early in life are likely to be
continuous and influence attachment later in adult relationships. Therefore, negative attachment
experiences in childhood may lead one to develop negative relationship patterns in adulthood
based on dysfunctional interpersonal schemas (e.g., rejection, distrust, abandonment) (Hammen,

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Burge, Daley, Davila, Paley & Rudolph, 1995). According to the interpersonal vulnerability
perspective, individuals with dysfunctional interpersonal cognitions are likely to develop
depression when faced with negative interpersonal life events, such as conflicts, divorce, job
loss, or loss of a close friend due to illness or relocation (Hammen, Burge, Daley, Davila, Paley
& Rudolph, 1995).
This perspective has implications for the present study because of the relationship
between attachment cognitions and social support. That is, individual’s attachment cognitions
have been shown to be associated with their perception of social support (Herzberg, Hammen,
Burge, Daley, Davila & Lindberg, 1999). Hammen (2006) found that romantic partners of
depressed young women reported providing less social support, but the young women’s best
friends reported providing more social support. Interestingly, the young women perceived
receiving less social support from their best friend, indicating that their attachment cognitions
influence the way they perceive the social support they actually receive.
This is important to the present studies because perceived access to social support has
been found in some studies to buffer the relationship between life events and levels of depressive
symptoms (Coiro, 2001; Dennis, Parke, Coltrane, Blacher, & Borthwick-Duffy, 2003; Ennis,
Hobfall & Schroder, 2000). Social support also can be seen as an important component of
resilience processes in response to the stress of depressive episodes, as described in a later
section.

Summary
The current section provided a broad discussion on the complex nature of depression,
including several components of depression, such as genetic and neurobiological aspects, and

50

cognitive and interpersonal aspects (see Gotlib & Hammen, 2009; and Joiner, Brown & Kistner,
2006). These components of depression are conceptualized in the psychological literature as
vulnerabilities that interact with environmental or situational stressors, leading to a depressive
episode. In connection with the proposed ecological-resilience theoretical framework for this
dissertation, these vulnerabilities represent potential characteristics or attributes the developing
individual (rural mother in these studies) possesses with which to interact with family and
environmental stressors.
Depression in Women and Factors Associated with Maternal Depression
This section narrows the discussion to the literature on depression among rural lowincome women. It begins with a broad explanation of gender differences to explain some of the
reasons why women are more likely to suffer from depression than men. The discussion then
narrows to factors that are associated with depression among mothers, such as parental
confidence, social support, and perceived economic strain. Finally, this section further narrows
to factors related to maternal depression among rural low income women, and ends with a
summary of findings from the Rural Families Speak project.
Depression in Women
The research has been clear and consistent that major depressive disorder is twice as
common in women as in men (Kessler et al., 2003; Nolen-Hoeksema & Hilt, 2009; Substance
Abuse and Mental Health Services Administration, 2010). What has been less clear and
consistent are the reasons for the persistent gender differences. Based on the literature, the
complexity of the reasons for and nature of the gender differences is consistent with the
complexity of the disorder itself. Depression, as stated previously, is complex because of its
variability and heterogeneity. There are many potential causes and the onset, duration,

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recurrence, and episodic nature of depression make it difficult to measure as a construct
(Hammen, 2009). For example, it has been found that women have a greater number of first
onsets of depression (Nolen-Hoeksema & Hilt, 2009), and this gender difference begins in early
adolescence between the ages of 13 and 15, is greatest between 15 and 18 (Hankin, Abramson,
Moffitt, Silva, McGee & Angell, 1998), and continues over the life span (Leach, Christensen,
Mackinnon, Windsor & Butterworth, 2008). However, several studies indicate that there are no
gender differences in the severity or length of depressive episodes (as discussed in NolenHoeksema & Hilt, 2009).
Some studies focus on biological explanations for gender differences, particularly
hormonal differences and genetic factors. For instance, because gender differences do not
appear until early adolescence, the hormonal changes occurring at puberty are thought to be a
possible explanation, the timing of puberty in particular (Nolen-Hoeksema & Hilt, 2009).
Several studies have shown that girls who mature faster than their peers are at a higher risk for
developing depression and several other psychological disorders (Conley & Rudolph, 2009; Ge,
Kim, Brody, Conger, Simons, Gibbons, et. al., 2003; and as discussed in Nolen-Hoeksema &
Hilt, 2009). Other hormonally based explanations during other stages of life include the
premenstrual phase of the menstrual cycle, postpartum depression, and menopause (NolenHoeksema & Hilt, 2009). Goldberg (2006) proposed that there is a genetic explanation related to
estrogen cycles that contribute to gender differences.
Psychological explanations for the gender differences in depression include interpersonal
vulnerability and rumination (Nolen-Hoeksema & Hilt, 2009), as described in previous sections.
Women are more likely than men to develop self-concepts that are relative to their roles in life
and the relationships they develop (Nolen-Hoeksema & Hilt, 2009). Cambron, Acitelli and Pettit

52

(2009) propose that women are more likely to develop interpersonally contingent self-esteem
(ICSE) than men. That is, their self-esteem is contingent upon the quality of their interpersonal
relationships. The authors explain that such behaviors as reassurance seeking and negative
feedback seeking tend to worsen interpersonal relationships and increase depressive symptoms.
Other research related to rumination have found that women are more likely than men to
ruminate in response to sad moods or negative life events (Nolen-Hoeksema & Hilt, 2009).
Further, it has been found that rumination predicts new onsets of a major depressive episode, but
does not predict duration (Nolen-Hoeksema, Wisco & Lyubomursky, 2008), which parallels
findings about gender differences in the onset, but not duration of depressive episodes.
Socially related explanations of the gender differences are centered on negative life
events that women are more likely to face than men, such as traumatic events and childhood
adversity (Nolen-Hoeksema & Hilt, 2009). These authors explain that women are more likely
than men to experience physical and sexual abuse in childhood and adulthood, and girls are more
likely to be affected by their mothers’ depression as a childhood adversity than boys.
Depression and Parenting Confidence
A sense of confidence in one’s parenting abilities has been found in the literature to have
mediating effects in regard to several parenting stressors (e.g., personality or depression) and
their relationships to child outcomes. However, there are inconsistencies in the terminology used
for this concept in the literature. Parental confidence, parental competence, and parental sense of
self-efficacy have each been used in research on parenting, and all seem to be defined similarly.
Ontai, Sano and colleagues (2008) defined parental confidence as “the degree to which parents
perceive themselves as capable and effective in the parenting role” (p. 325). They equated the
term as synonymous with self-efficacy. Parental sense of competence has been defined as “the

53

belief of parents that they can effectively manage parenting tasks” (de Haan, Prinzie & Dekovic,
2009). These authors also stated that parental sense of competence is synonymous with
parenting self-efficacy. However, Coleman and Karraker (2003) defined self-efficacy beliefs as
“parents’ self referent estimations of competence in the parental role” (p. 128), and they further
conceptualized it as “parents’ perceived ability to positively influence the behavior and
development of their children” (p. 128). The distinctions between the terms are slight, but it
appears that parental self confidence is synonymous with parenting self-efficacy beliefs in that
they focus more on the internal perceptions and beliefs of the parent about their parenting
abilities. Conversely, parental competence reflects the overt parenting behaviors performed in
order to influence child behaviors and development.
To be consistent with the larger Rural Families Speak project, the present studies use the
term parental confidence and the definition put forth by Ontai, Sano and colleagues (2008, also
connected with Rural Families Speak). However, this section of the literature review will use the
terms as used in their respective studies.
In their study, Ontai, Sano, Hatton and Conger (2008) used parental confidence as their
dependent variable and found that rural low-income mothers’ parental confidence was directly
influenced by the presence of family health problems, which were conceptualized by the authors
as daily hassles. However, the relationship was mediated by the presence of parental support for
mothers with partners, but not for single mothers. That is, the strength of the negative influence
of family health problems on parental confidence was decreased when rural mothers were
married or had a partner living in the home. It appears that for the daily hassles of family health
problems, having another adult in the home helps alleviate the strains brought on by those daily
hassles.

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Most studies employ parental confidence as a mediating or moderating variable. For
example, Knoche, Givens & Sheridan (2007) found that adolescent mothers with high levels of
depression but whom also had a high sense of parental competence had children who scored
higher on cognitive tests. This is in comparison to adolescent mothers reporting high levels of
depression and a low sense of parental competence, whose children scored lower on cognitive
tests.
A sense of parental competence also has been found to be an important mediator for the
influence of parents’ personality characteristics (e.g., extraversion and agreeableness) and their
parenting characteristics (e.g., warmth, overreactivity) (de Haan, Prinzie & Dekovic, 2009).
These authors were able to show that a sense of parental competence is a mechanism by which
parents’ personality influences their parenting behaviors. In another study, Jackson and Scheines
(2005) found that parent self-efficacy beliefs were a mechanism which mediated the effects of
maternal employment on parenting behaviors and child outcomes.
Thus the research points to the importance of parental confidence to family relationships
and functioning. Parental confidence can be a protective factor for families, and was shown in
the research discussed to be an important process variable. It is important that researchers
continue to explore the nature and interactions between parental confidence and several family
outcomes, as well as interactions with other process variable, such as social support. Social
support was reported earlier to mediate the relationship between family health problems and
parental confidence in our sample of rural low-income women (Ontai, Sano, Hatton and Conger,
2008). Similarly, Bulock (2004, 2007) found that parental social support (that is, social support
specific to the parenting role) mediated the relationship between parental confidence and

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maternal depression among rural low-income women. The following section further discusses
the role of social support in depression among mothers.
Depression and Social Support
A concept that is important to this study, and links the resilience and depression literature
is social support. Important sources of social supports for individuals include close and caring
relationships with parents and other competent adults, associating with prosocial peers, and
connections to positive community assets such as clubs, religious groups and libraries (Masten
and Powell, 2003). Similarly, several models used in the family resilience literature (McCubbin
& Patterson, 1983; Olsen, 1993; Patterson, 2002) point to the importance of families tapping into
resources both inside and outside of the family, which can include social support.
Studies on the relationship between social support and maternal depression have yielded
mixed results, both in the depression literature and in other Rural Families Speak studies. For
instance, results from Hammen’s (2006) study of young women transitioning to adulthood
suggested that depressed participants perceived receiving less social support than their friends
actually reported providing to them. Conversely, Islam (2004) used the Rural Families Speak
dataset and found that mothers with perceptions of high social support reported fewer depressive
symptoms, and that social support acted as a moderator for participants who had maintained their
marital status over time. Interestingly, Richards and associates (2002), found that participants
with the lowest levels of depression perceived high levels of social support which had no strings
attached (that is, no expectations of reciprocity). However, those with the highest levels of
depression felt that social support came with strings attached. Brown, Brody and Stoneman
(2000) reported in their study of rural black mothers that support from one’s spouse was an
important buffer for depression under conditions of significant socioeconomic risk. These

56

studies are consistent with classic research on the stress process (Pearlin, Menaghan, Lieberman,
& Mullan, 1981) which suggests that social supports act to buffer depression indirectly by
reinforcing self-concepts and are beneficial to those who need it most. The findings from
Brown, Brody and Stoneman (2000), Hammen (2006), Islam (2004), and Ross and Mirowsky
(1989), suggest that support received from a spouse, or other non-resident parent, is more
effective for buffering depression than support received from social networks.
Maternal Depression and Economic Risk
The link between maternal depression and economic risk and strain has been well
documented in the literature. In their review of the literature, Brown, Brody and Stoneman
(2000) articulate some of the processes by which economic risk exacts its toll on depression in
women. For instance, economic risk can result in undermining a mother’s sense of parental
efficacy, and can increase a woman’s exposure to stressful conditions such as living in dangerous
neighborhoods where housing for the family may be inadequate. Their research (2000) revealed
interesting findings about the relationships between maternal depression, economic risk, and
family dynamics. In their sample of rural Black women, maternal depression was strongly
associated with difficult child conduct. However, that relationship was moderated by the
family’s level of economic risk. That is, under conditions of high economic risk, mothers’
depression was strongly associated with difficult child conduct. When economic risk was low,
however, the relationship between mothers’ depression and child conduct was reduced to
statistical non-significance.

Even more interesting were their findings in regard to marital

support, or more specifically, social support for childrearing provided by husbands. They found
that marital support was not related to mothers’ depression when economic risk was low, but was
negatively related to mothers’ depression when economic risk was high. That is, the parental

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social support mothers receive from their husbands helps to buffer the relationship between
mothers’ depression and the strain they experience from economic risk.
In the context of welfare reform, the association between maternal depression and
economic strain can be complex. For instance, self-reported maternal depressive symptoms have
been shown to be associated with reduced or loss of welfare benefits and food stamps, food
insecurity, and child health problems (Casey, Goolsby, Berkowitz, Frank, Cook, Cutts, et.al,
2004). Other studies have shown similar findings. For instance, several studies stemming from
the Rural Families Speak project have found depression among rural mothers to be associated
with food insecurity (Bulock, 2007; Olson, Anderson, Kiss, Lawrence, & Seiling, 2004), and
perceived economic strain (Dolan, Richards, Sano, Bauer, & Braun, 2005).
One of the mechanisms by which economic risk and other life circumstances has been
found to influence depression is through the subjective perceptions, or meanings, a person holds
about his or her situation. Pearlin, Lieberman, Menaghan and Mullan (1981) eloquently
described this mechanism in their classic development of the stress process model, “life events…
lead to stress by adversely altering the meaning of persistent life strains” (p. 339). Dennis,
Parke, Coltrane, Blancher, and Borthwick-Duffy (2003) presented an example of this mechanism
in their study of low-income Latina mothers living in Southern California. In their sample, the
objective indicator of having a low income was not directly related to depression in the mothers.
Instead, the mothers’ own subjective feelings about not having enough money to make ends meet
were related to their levels of depression. Similarly, in a study stemming from the Rural
Families Speak project, Dolan, Richards, Sano, Bauer, & Braun (2005) found that rural mothers’
employment instability, along with their perceptions that their financial situation had declined
over time, were associated with increased depression, whereas household income differences

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over time were not associated with their depression levels. Because of these findings, it will be
important in the present study to include indicators that both measure rural families’ economic
conditions objectively (e.g. household income, percentage of the poverty level, etc.), and
measure rural mothers’ subjective perceptions and meanings of their economic situation to
understand the links between rural mothers’ mental well-being and their families’ well-being.
Family Challenges in the Context of Welfare Reform
Heymann (2000, 2002) documented several risks working poor families across the
country face, including low income, underemployment, health problems, child problems in
school, child behavior problems, child disabilities, problems with transportation, and challenges
with the work-life time crunch. Within the context of a global, 24-hour economy, low-income
parents often must work irregular shifts to accommodate employers’ needs, but lose time with
their families and struggle to find adequate child care for off-peak hours. In addition, most lowincome workers receive few basic benefits from their employers, such as health insurance
coverage, vacation and sick time, and overtime pay. Thus many low-income workers are
working long hours with little pay. They struggle to make ends meet, and to meet the physical
and emotional needs of their families.
Lichter and Jayakody (2002) report that most welfare to work programs were developed
from an urban-based context. However, working poor families in rural areas face unique
challenges and risks compared to working poor families in urban settings. These challenges
include isolation, limited employment (Braun, Lawrence, Dyk & Vandergriff-Avery, 2002) and
educational opportunities, and poverty extended over longer periods of time (Ames, Brosi, &
Damiano-Teixeira, 2003). Transportation can become a problem for rural families because most
workplaces and childcare locations are separated by long distances from the family’s home.

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Many employers in rural areas do not provide basic benefit packages that include health
insurance or vacation or sick time (Heymann, 2000 & 2002). Thus, the realities of rural life and
the nature of welfare reform legislation may actually make it harder for poor families to make
ends meet (Bauer, Braun & Olson, 2000; Cheng, 2002; Lichter and Jayakody, 2002).
Many of the mothers in the Rural Families Speak project reported that, while having a job
helped their family’s economic well-being to a point, many were still living in poverty and
needed public assistance. Merely having a job did not make them economically self-sufficient
(Braun, Lawrence, Dyk & Vandergriff-Avery, 2002). In addition, these authors’ findings
indicated that many families did not receive the assistance for which they were eligible (e.g.,
earned income tax credit, food stamps), and that eligibility varied by state. Another study from
the Rural Studies Speak project found that child care challenges made finding and keeping a job
difficult (Plumb & Braun, 2007). For instance, for low-skilled women with entry level jobs, the
costs of child care were almost equal to their income, taking most of their earnings. In addition,
it was often difficult to find available child care during non-standard work hours, such as nights
or weekends.
However, poverty and associated economic hardships also are discussed in much of the
literature on maternal depression as life events which trigger coping responses as well as strains
(Brown, Brody & Stoneman, 2000; Casey, et.al., 2004; Coiro, 2001; Dennis, Parke, Coltrane,
Blacher, & Borthwick-Duffy, 2003; Ennis, Hobfall & Schroder, 2000; Jackson, 1998, 1999;
Jackson & Huang, 1998; Ross, 2000; Siefert, Heflin, Corcoran, & Williams, D. 2004; Taylor,
Rodriguez, Seaton, & Dominguez, 2004). In these studies, mothers who tapped into social
support resources reported fewer depressive symptoms. Consistent with the resilience
framework, mothers’ perceived social support and their perceptions of their economic situations

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are conceptualized as resources that influence their well-being, which in turn influences the wellbeing of the family.
The Rural Families Project Findings Related To Depression
This study uses data from the Rural Families Speak project, which is a multidisciplinary,
mixed method, and longitudinal approach to developing an understanding of the challenges and
complexities faced by rural low-income families within the context of their communities. Rural
families are faced with limited employment opportunities and therefore higher poverty rates,
limited educational and training opportunities, and difficulty maintaining dependable, affordable
childcare and transportation (Bauer, Braun, & Dyk, 2003; and Findeis, Henry, Hirschl, Lewis,
Ortega-Sanchez, Peine, & Zimmerman, 2001). Many of the studies stemming from the Rural
Families Speak project have focused on factors related to the mental well-being of rural mothers
in the sample, with depression being one of the most used indicators of maternal mental health.
Though the studies are varied in design and methods, with some using a single wave of data for
analyses and others using longitudinal designs, common themes have emerged in relation to
maternal depression:
1). Mothers’ perceptions of life satisfaction and confidence in their parenting ability (Bulock,
2004), and social support (Bulock, 2004; Bulock, in process; Islam, 2004; Garrison, Marks,
Lawrence & Braun, 2004; and Kim, Seiling, Stafford & Richards, 2005) are associated with
lower depression.
2). Food insecurity (Bulock, 2007; and Olson, Anderson, Kiss, Lawrence, & Seiling, 2004),
tobacco use (Maring & Braun, 2005) and perceived economic strain (Bulock, in process; and
Dolan, Richards, Sano, Bauer, & Braun, 2005) are associated with higher depression.

61

3). Employment status, especially continued employment status over time, is related to lower
depression (Dolan, Richards, Sano, Bauer, & Braun, 2005; and Kim, Seiling, Stafford &
Richards, 2005).
4). The relationship between low income and depression is mediated by mothers’ perceived
economic strain. That is, annual income relates to higher depression when mothers perceived
more economic strain (Bulock, in process).
5). Stronger religious beliefs and faith community involvement is associated with lower
depression (Garrison, Marks, Lawrence & Braun, 2004).
6). Inability to build resources during times of change is associated with higher levels of
depression (Seiling, 2006).
7). Having experience with health care systems and more knowledge of depressive
symptomotology is associated with the likelihood that rural low-income mothers’ will self-report
their depressive symptoms (Simmons, Huddleston-Casas & Berry, 2007).
Summary of the Literature Review
This chapter began with a discussion of the theoretical frameworks used for this
dissertation. Specifically, the resilience framework was compared with and tied to an ecological
framework in two ways. First, connections were made between the human ecological approach
(Bronfenbrenner, 1986, 1989, 1994, and as discussed by Tudge, Mokrova, Hatfield & Karnik,
2009) and the resilience approach at the individual level. Second, connections were made
between the family ecological approach (Bubolz & Sontag, 1993) and the resilience approach at
the family level. Rationale were provided for the use of this integrated framework for the study
of resilience processes among rural low-income mothers and their families, as well as for the

62

study of the ways in which rural mothers’ longitudinal depression patterns shape resilience
processes.
The discussion then turned to the broad and complex nature of depression, describing
vulnerabilities that are associated with depression, such as brain structures and mechanisms,
cognitive and personality attributes, and interpersonal issues. The gendered nature of depression
was then highlighted, particularly the ways that women are affected. The last sections outlined
various correlates with maternal depression that are important to the present studies, such as
parental confidence, social support and poverty. The chapter ended with an overview of findings
from the Rural Families Speak study that are relevant to this dissertation.
The following two chapters present two manuscripts. The purpose of study 1 is to glean
an understanding of the contextual influences on mothers’ depression patterns over time. The
purpose of study 2 is to understand which individual and family risk and resilience factors and
processes were most relevant for each longitudinal pattern of depression.

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CHAPTER 3
STUDY 1: PICTURES OF RESILIENCE AMONG RURAL
LOW-INCOME MOTHERS: A MIXED METHODS STUDY
Abstract
A mixed methods approach was used to explore variability in eighteen rural low-income
mothers’ longitudinal depression patterns. In addition, a resilience lens was employed to identify
resilience processes adapted by the mothers and their families. Consistent with a concurrent
triangulation design, quantitative analyses were conducted to place mothers within longitudinal
depression patterns for subsequent in-depth analysis using grounded theory techniques. Similar
themes emerged among all of the participants in the study. However, the picture of resilience
expressed within these themes varied by depression pattern, as did the nature and the number of
sources of stress and sources of strength. Findings highlight the complexity of resilience
processes in the face of maternal depression among rural low-income women. Implications for
policy and practice are discussed.

Keywords: maternal depression, stress, resilience, social support, perception, parenting

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Introduction
Major depression is the leading cause of disability in the United States (US Department
of Health and Human Services, 1999), and it is twice as common in women (Kessler et al.,
2003), especially those of child-bearing ages (18-45 years old) (Substance Abuse and Mental
Health Services Administration, 2010). Mothers with young children seem to be especially
vulnerable to depression (Mistry, Stevens, Sareen, De Vogli & Halfon, 2007; Zuckerman &
Beardslee, 1987). Women play important roles in the nurturing and development of family
members and the day-to-day management of family functioning. However, the capacity to carry
out such roles is compromised when women experience depression. The child development
literature has produced numerous studies on the relationship between maternal depression and
poor child outcomes, such as poor child health (Casey, Goolsby, Berkowitz, Frank et. al, 2004),
child disruptive behaviors (Gross, Shaw, Burwell & Nagin, 2009; Turney, 2011; and Mustillo,
Dorsey, Conover & Burns, 2011), deficits in cognitive performance, and dysfunctions in
behavioral regulation among infants and young children (for a more extensive review see
Hammen, 2003).
Social science research has increasingly focused on the correlates and detrimental effects
of depression in mothers, as well as some of the processes by which maternal depression is
related to family dynamics. Most of the literature to date has examined maternal depression
from a risk-only perspective. In addition, much of the research on maternal depression has been
cross-sectional and quantitative. Consequently, less is known about the context of mothers’ lives
as they experience variability in their depression over time, and less is known about the complex
interplay among individual and family risk and protective processes experienced in their
families. This research employs a mixed methods design and a resilience perspective to explore

65

the context in which depression occurs in these mothers’ lives, and to identify risk and resilience
factors and coping mechanisms mothers and their families develop to off-set the demands related
to mothers’ longitudinal depression patterns.
Resilience Framework
This study employs a resilience approach to studying individuals and families. Currently
individual and family resilience are seen as two separate frameworks with separate literature
bases and lines of research, although family researchers borrow concepts and constructs from
individual resilience research. Family resilience is a systems level framework, yet family
systems are made up of individuals whose health, attitudes and development contribute to whole
family system functioning.
While family has been conceptualized as both a risk and a protective factor influencing
individual resilience (see several chapters of Luthar, 2003), less is known about the influence of
the individual on family resilience (Hawley & DeHaan, 1996). In addition, studies of individual
risk and resilience have focused on child and adolescent development (see several chapters of
Luthar, 2003; Clark & Clark, 2000; Felsman, 1989), or on adult outcomes of adolescent risk
experiences and resilience processes (Higgins, 1994; Quinton, Rutter & Liddle, 1984; Rubin,
1996). In order to make a better link between the two frameworks, it is important to understand
how resilience takes shape within adults in families and how their resilience may be related to
family level development. Therefore, this study brings these two lines of research together as a
cohesive and comprehensive resilience framework. Given the pivotal role mothers play in
families, it makes sense to begin linking individual and family resilience frameworks with a
study of mothers and how their individual resilience relates to family resilience in the context of
rural poverty and welfare reform.

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Similar to Conger and Conger (2002), this study will adopt the broad definition of resilience
proposed by Luthar, Cicchetti and Becker (2000) to conceptualize resilience at the individual and
family levels: “Resilience refers to a dynamic process encompassing positive adaptation within
the context of significant adversity.” (p. 543). In addition to being applicable to resilience at
multiple levels, this definition is important because it implies two conditions by which an
individual or family could be deemed resilient. First, there has been exposure to significant
adversity, and second, an achievement of positive adaptation, or competent functioning and
development has been reached, despite the exposure to risk (Hawley and DeHaan, 1996; Luthar,
Cicchetti & Becker; Patterson, 2002a, 2002b). Individuals and families face varying risks,
possess varying personal or family-level attributes, and have access to a variety of support
resources. In addition, resilience processes occur over time and within a developmental context.
Thus, within the context of adversity, individual and family functioning varies across
developmental and family function domains (Luthar, Cicchetti & Becker, 2003; Patterson, 2002).
The Importance of Perception
In addition to concepts of risk and resilience and adaptive processes, two other concepts
link the individual and family literature sets, and also link with literature on depression. The first
is the concept of perception. Literature on individual resilience has found that positive selfperception (competence, worth, confidence, and self-efficacy) and positive outlook on life
(hopefulness, belief that life has meaning, and faith) is associated with positive outcomes
(Masten, 2001; Masten & Powell, 2003). Similarly, several models of family stress and
resilience processes highlight the important role of family perceptions of situations and family
meanings for positive adaptation to adversity (Lavee & Olson, 1991; McCubbin & Patterson,
1983; Patterson, 2002). Cognitive theories of depression point to the importance of perception

67

for influencing the way negative life events are interpreted and acted upon (Abramson & Alloy,
2006; Joormann, 2009). Perceptions influence the way individuals filter information from the
environment and develop schemas about life (Joormann, 2009). Such schemas influence
whether life circumstances are viewed as hopeless (Abramson, Metalsky & Alloy, 1989), or as
areas for improvement, which would be consistent with an adaptive (resilient) outlook. Thus, it
is clear that perceptions play a key role in the ability to “bounce back” from crisis.

Social Support Matters
The second concept that is important to this study, and links the literature sets is social
support. Important sources of social support for individuals include close and caring
relationships with spouses, parents and other competent adults, associating with prosocial peers,
and connections to positive community assets such as clubs, religious groups and libraries
(Masten and Powell, 2003). Similarly, several models used in the family resilience literature
(McCubbin & Patterson, 1983; Olsen, 1993; Patterson, 2002) point to the importance of families
tapping into resources both inside and outside of the family.
Studies on the relationship between social support and maternal depression have yielded
mixed results, both in the depression literature and in other Rural Families Speak studies.
Interpersonal vulnerability theories of depression are informed by Bowlby’s theory of
attachment, which posits that humans need to maintain a relatedness with others for survival
(Bell, 2009). From the interpersonal vulnerability perspective, individuals’ attachment
cognitions have been shown to be associated with both their perception of social support and
enacted social support (Herzberg, Hammen, Burge, Daley, Davila & Lindberg, 1999). For
instance, results from Hammen’s (2006) study of young women transitioning to adulthood

68

suggested that depressed participants perceived receiving less social support than their friends
actually reported providing to them.
Islam (2004) used the Rural Families Speak dataset and found that mothers with
perceptions of high social support reported fewer depressive symptoms, and that social support
acted as a moderator for participants who had maintained their marital status over time.
Interestingly, Richards and associates (2002), using Rural Families Speak data, found that
participants with the lowest levels of depression perceived high levels of social support which
had no expectations of reciprocity. However, those with the highest levels of depression felt that
social support came with strings attached. Brown, Brody and Stoneman (2000) reported in their
study of rural black mothers that support from one’s spouse was an important buffer for
depression under conditions of significant socioeconomic risk. These studies are consistent with
classic research on the stress process (Pearlin, Menaghan, Lieberman, &Mullan, 1981) which
suggests that social supports act to buffer depression indirectly by reinforcing self-concepts and
are most beneficial to those who need it most. The findings from Brown, Brody and Stoneman
(2000), Hammen (2006), Islam (2004), and Ross and Mirowsky (1989), suggest that perceived
support received from a spouse, or other non-resident parent, is more effective for buffering
depression than support received from social networks.
The Present Study
The present study is guided by two research questions. First, “What accounts for the
depression patterns of rural low-income mothers over three waves of data collection?” Second,
“How do mothers’ perceptions, social supports, risks and the other contextual circumstances in
rural mothers’ lives differ when comparing mothers in each of the six depression categories?”

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Method
Data from the Rural Families Speak project were analyzed for this study. Rural Families
Speak was a multi-state project which employed a multidisciplinary, mixed method, and
longitudinal approach to develop an understanding of the challenges and complexities faced by
rural low-income families within the context of their communities. See Bauer (2004) and Bauer
and Dolan (2011) for more background information about Rural Families Speak project.
Sample
A purposive sample was selected for the Rural Families Speak study due to the difficulty
in obtaining a consistent multiple state random sample of rural low-income, highly mobile
families. Most states recruited participants through agricultural extension education programs
for low-income families. To be included in the study, it was required that each family have at
least one child 12 years old or younger living in the home. Families also had to be eligible for,
but not necessarily receiving, Food Stamps or the Supplemental Nutritional Program for Women
Infants and Children (WIC) at the time of the interviews, or have a poverty ratio less than 200%
of the poverty level limit. The sample included participants from four states in the Eastern
region, five in the Central region, two in the Southern, and four in the Western region.
Compared to poor rural families nationwide, the Rural Families Speak sample had a higher
proportion of rural Latino(a) families (17%), a lower proportion of White families (69% ), and a
lower proportion of rural Black families (6% ). Native American families (n=2, 0.9%) were not
targeted for recruitment due to complicated circumstances regarding tribal benefits and services.
The Rural Families Speak sample included 433 participants for wave one, 326
participants for wave two, and 271 for wave three. Attrition among those in the sample
occurred for several reasons. One state dropped from the study before wave two data were

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collected. Some participants from wave one did not meet the sampling criteria to be interviewed
for wave two (they were no longer eligible to receive assistance, their incomes rose above the
200 percent poverty limit, or their youngest child matured over the 12 year old age limit). Last,
many participants could not be contacted for subsequent interviews because they had moved.
The sample for the present study was selected in two steps. First, the sample was limited
to mothers who participated in all three waves of data collection (N = 223) so that longitudinal
depression patterns could be studied. Table 3.1 describes the sample at the first step. The second
step involved selecting cases from each depression pattern (described in more detail in analytic
approach, step two).
Table 3.1 Demographic Variables Characterized By Rural Mothers’ Depression Patterns

Age
M (SD)
Education
High school &
less
More than high
school
Ethnicity
White
Hispanic/Latino
African
American
Other
Marital status
Single
Married
Living
w/partner
Divorced
Separated

Low
n = 75
% (n)
31.2 (8.2)

Moderate
n = 25
% (n)
29.1 (6.8)

High
n = 14
% (n)
31.6 (7.4)

Improving
n = 48
% (n)
29.6 (7.0)

Worsening
n = 34
% (n)
30.2 (7.0)

H-L-H
n = 27
% (n)
32.6
(7.1)

30.6 (22)

9.7 (7)

6.9 (5)

26.4 (19)

16.7 (12)

9.7 (7)

34.0 (48)

12.1 (17)

5.7 (8)

19.9 (28)

15.6 (22)

12.8 (18)

30.7 (47)
40.6 (13)
33.3 (5)

10.5 (16)
12.5 (4)
26.7 (4)

7.8 (12)
0
0

20.9 (32)
21.9 (7)
26.7 (4)

16.3 (25)
15.6 (5)
6.7 (1)

13.7 (21)
9.4 (3)
6.7 (1)

40.0 (6)

0

6.7 (1)

33.3 (5)

20.0 (3)

0

31.5 (17)
39.0 (32)
22.9 (8)

11.1 (6)
7.3 (6)
17.1 (6)

7.4 (4)
4.9 (4)
5.7 (2)

20.4 (11)
23.2 (19)
34.3 (12)

16.7 (9)
12.2 (10)
14.3 (5)

13.0 (7)
13.4 (11)
5.7 (2)

31.0 (9)
33.3 (5)

13.8 (4)
13.3 (2)

6.9 (2)
6.7 (1)

17.2 (5)
6.7 (1)

17.2 (5)
33.3 (5)

13.8 (4)
6.7 (1)

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Data Collection
The project collected three waves of quantitative and qualitative data from 24 counties in
14 states. Protocols for each wave were approved by research ethics boards for each
participating site, and participants provided informed consent for each wave. Trained
interviewers in each state used semi-structured protocol to conduct interviews face-to-face with
the woman in the family for about two hours. Quantitative data included demographic, financial
and employment information, as well as information on the number of health and mental health
problems in the family and their access to health insurance and health care. Instruments included
the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977); the Parenting
Ladder (Richards, 1998); and the Core Food Security Module (Hamilton et al., 1997).
Qualitative protocol included open ended questions designed to probe more detailed
information about participants’ responses to the quantitative questions. For instance, when
asking mothers about their employment status, interviewers also would ask whether anything or
anyone made it more difficult for the mother to work. Likewise, after completing the CES-D and
the Parenting Ladder, interviewers would ask mothers to elaborate on items of interest. For
example, mothers were asked to rate themselves on the Parenting Ladder in terms of “your
overall satisfaction with the amount of support in your life,” after which interviewers asked the
mothers to explain why they rated themselves that way. The interviews were tape-recorded and
later transcribed for data analysis.
Analytic Approach
Although the data for the larger Rural Families Speak study and for this study were
collected consistent with a concurrent design, the analysis for this mixed methods study was
conducted in three steps, and was more consistent with a sequential explanatory design (Creswell

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& Plano Clark, 2007; Creswell, Plano Clark, Gutmann, & Hanson, 2003) in that quantitative
analyses were conducted (in the first two steps) in order to characterize mothers according to
longitudinal depression patterns. These results were then “used to guide the purposeful sampling
of participants for a primarily qualitative study” (Creswell, Plano Clark, Gutmann, & Hanson,
2003, p. 227). That is, mothers from the sample described above (N = 223) were each placed
within a longitudinal depression pattern, and then a subsample was selected from each pattern for
in-depth qualitative analysis (step three).
Step One. Maternal depression was measured using the Center for Epidemiologic
Studies Depression Scale (CES-D), which was designed to measure symptoms of depression in
the general public (Radloff, 1977). Studies testing validity have shown that the CES-D is highly
correlated with other measures of depression (Radloff, 1977). The 20-item inventory has a
reported high internal reliability, with Cronbach’s alpha of 0.82 (Radloff, 1977). Cronbach’s
alpha for the current sample (N = 223) is 0.89. For the first step in the quantitative analysis,
mothers’ depression scores for each year of data collection were coded into four categories
according to Seligman’s recommendation (1998).

Table 3.2. Number Of Mothers In Each Depression Category
Depression Category

Depression score range

Nondepressed
Mildly depressed
Moderately depressed
Severely depressed

0-9
10-15
16-24
>24

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Wave 1
n = 223 (%)
59 (26)
51 (23)
62 (28)
51(23)

Wave 2
n = 223 (%)
83 (37)
61 (27)
49 (22)
30 (14)

Wave 3
n = 223 (%)
85 (38)
52 (23)
42 (19)
44 (20)

Table 3.2 reflects the changes occurring in depression over time in an aggregated sense.
When looking at changes across the whole sample, it appears that the number of mothers with no
depression increased, and the number of mothers with moderate or severe depression decreased.
Step Two. The above step allowed for comparisons of the levels of depression across all
three years for the sample. However, this snapshot is more complicated when comparisons are
made across all three years for each mother. Such comparisons led to the emergence of
longitudinal depression patterns. That is, upon examining depression at each wave for each
mother, it became clear that depression levels varied greatly for many mothers each year.
Therefore, in the second step of the quantitative analysis, each mother was placed into one of six
longitudinal “depression patterns”:


“Stable low” pattern consisted of mothers who reported depressive symptoms consistent
with categories one and two (nondepressed and mildly depressed), and who remained in
those low categories across time (low  low  low) (n = 73).



“Stable moderate” pattern consisted of mothers who reported depressive symptoms in the
moderately depressed range over time (mod  mod  mod) (n = 15).



“High depression” pattern consisted of mothers whose depression remained in the
severely depressed category all three waves (high  high  high) (n = 13).



“Improving depression” consisted of mothers who experienced high levels of depression
the first wave, but reported much lower symptom levels by the second and third waves
(high  low  low) (n = 48).



“Worsening depression” consisted of mothers experiencing few depressive symptoms
during the first wave, but more severe depressive symptoms over the next two waves
(low  high  high) (n = 34).
74



Finally, for some mothers the pattern was “erratic”, such that the reported symptom
levels changed dramatically each year of data collection (high  low  high) (n = 28).

An additional seventh pattern was identified that was also erratic (low  high  low),
however upon closer inspection of each mother (n = 13), the depression scores for each wave did
not differ as dramatically as the erratic pattern described above. The majority of participants
fitting this pattern had scores that remained in the mild to moderate range over the length of the
study. Therefore, mothers in this depression pattern were included with mothers in the “stable
moderate” pattern (making that subsample n = 28).
This step in the analysis raised many questions about the nature of the mothers’ depression
patterns and how they looked in the context of mothers’ lives. It was important at this juncture
to understand the mothers’ stories which might shed light on the longitudinal patterns that
emerged from the data.
Step Three. The third step involved qualitative analysis of three cases from each of the
depression patterns (final n = 18 cases total). Extreme cases in each pattern were selected in
order to gain an understanding of the contextual differences in the depression patterns, and to
observe differences in risk and resilience processes across the patterns. Guided by the research
question and conceptual framework, comparing and contrasting multiple cases within and across
the patterns can “strengthen the precision, the validity, and the stability of findings” (Miles and
Huberman, 1994, p. 29). Thus, for each pattern, cases were selected based on extreme
depression score values. Mothers with the consistently lowest depression scores were selected
for the low depression pattern. Mothers with the consistently highest depression scores were
selected for the high pattern. For the improving, worsening and erratic patterns, mothers were

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selected for the extreme differences in depression scores across all three waves, according to
their pattern.
Themes from the analyses will be presented, with the goal of providing an understanding of
the risk and resilience processes and the variability in depression patterns among rural lowincome mothers. For each case, the mothers’ transcripts for all three years were analyzed. Thus
a total of 54 transcripts were coded and analyzed (three mothers X six depression patterns X
three transcripts) using MaxQDA software (Belous, 2007). The objective of the qualitative
analysis was to employ a grounded theory approach (LaRossa, 2005) to gain an understanding of
the context in which these patterns occur, and the ways in which those patterns relate to family
relationships, functioning, and meanings, as well as risk and resilience processes.
First, open coding was conducted of all transcripts using the variable-concept-indicator
model. An indicator is a word, phrase, or string of words and phrases in the data (e.g., “...you
just kind of keep looking the positives”). A concept is the label or code that is assigned to
represent indicators that are theoretically similar (e.g., positive perspective, parenting strengths,
stressful relationships). The constant comparative procedure outlined by LaRossa was applied
during open coding, linking indicators to concepts, and to each other until the concepts were
theoretically saturated.
The next step was axial coding. According to LaRossa (2005), this step involves the
discovery of relationships among concepts and creating higher level categories that pull the data
together, such as Primary Sources of Stress and Primary Sources of Strength. Axial coding
allows for the exploration of categories and determining their properties and dimensions. It was
during axial coding that specific relationships emerged between the higher level categories and
each depression pattern.

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Last, selective coding was done to “decide the main story underlying the analysis”
(LaRossa, 2005, p. 850). Similar to axial coding, selective coding involves the identification of a
core variable. However, according to LaRossa, the core variable “is a variable that has ‘analytic
power’ because of ‘its ability to pull the other categories [variables] together to form an
explanatory whole” (p. 851). During this analytic process, Pictures of Resilience emerged as the
core variable that pulled the concepts and categories together.
Findings
Across all three waves of data similar themes emerged among all of the participants in
the study (n = 18). However, the pictures of resilience expressed within these themes varied by
depression pattern, as expressed in the higher level categories sources of stress and sources of
strength. Thus the resilience process for women in the “stable low” pattern looked very different
from those in the “high depression” or the “worsening depression,” even though some of the
same themes were present. For comparison’s sake, a table of themes (Table 3.3) for each
pattern is presented, followed by a presentation of findings which helps to provide a context for
understanding how the picture of resilience processes varied for each depression pattern.

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Table 3.3. Primary Themes for Each Depression Pattern

Primary Sources of
Strength

Primary Sources of
Stress

Stable Low

Stable Moderate

High Depression

• Financial strains
• Negative life
events

• Negative outlook
• Stressful
relationships
• Financial strains
• Low perceived
access to social
support

• Positive
perspective
• Parenting
strengths
• Perceived family
strengths
• Resourceful
partner/spouse
• Social support

• Parenting
strengths
• Permanent
employment

• Pile-up of health
problems
• Financial strains
• “Getting the runaround”
• History of abuse
• Stressful
relationships
• Parenting strengths
• Positive
perspective
• Perceived family
strengths
• Informal social
supports

78

Improving
Depression
• Negative life
events
• Financial strains
• Health problems

Worsening
Depression
• Pile-up of health
problems
• Financial strains
• “Getting the runaround”
• Lowest amount of
social support

• Social supports
• Positive
perspective
• Investing in self
• Perceived
family strengths

• Positive
perspective
• Parenting
strengths

Erratic Depression
• Health problems
• Financial strains
• Stressful
relationships
• “Getting the runaround”
• Positive
perspective
• Parenting
strengths
• Investing in self
• Social supports
• Perceived family
strengths

“Stable Low” Depression
The women who reported no depression or mild depression across all three waves
reported the fewest number of risk factors, but when specific risk factors are considered, they
reported a higher number of negative life circumstances than most of the other women, and they
also reported a high level of perceived financial strains. For instance, Reba’s story (age 34)
provides a good example of how negative life events and financial strains can compound stress.
The combination of facing bankruptcy and losing many cows to an unknown disease put them in
danger of losing their farm and their home:
In June we were getting real desperate. Didn’t have hardly any food left. We had
a beef butchered at the locker but we were unable to get [it] ‘cause we just didn’t
have the funds. . . We had lost a lot of cows …We had lots of tests run and vets
could never really confirm why our cows died so our milk took a real plummet
‘cause we’d lost about 18 head at that time. That really took a big chunk of our
income so…when the milk check came, there wasn’t anything left. By the time
they took it out for our payments, we had about $28 to our name, and $28 isn’t
gonna buy groceries. It’s not gonna pay our electric bill, and our telephone bill.
So we went to see a lawyer and he thought that staying on the farm might be our
best option. It’s almost like, at that point, it’s really hard ‘cause you can’t get in
and you can’t get out.
In spite of such difficulties, the women in the stable low pattern reported the second
highest number of protective factors. These protective factors were active tools the women used
to work through current stressors or move on from past ones. For example, they were more
likely to have a positive perspective about their lives and were likely to look ahead. Joelle (age
37) explains why, despite being abused by former partners, she is satisfied with life with her two
children and plans for move forward:
I'm happy with what my kids are doing. We are healthy. I'm planning to go back
to school, I'm excited about that. . . considering where I've come from, where my
daughter was a year ago, where I was a little over a year ago, I feel that we're in
a good place right now, and we're stable.

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By the third year of the study, Joelle had put her plan in place. She was taking college courses
and training for a new job. Her daughter graduated from high school, and her son was in Head
Start while she worked. Both children were developing normally. She took an active role in
moving her life forward from past stressors.
The stable low women perceived parenting strengths in themselves and in their partners,
and talked about family strengths more than women who were depressed. They were likely to
perceive receiving social support from their husband or partner, and were likely to tap into other
informal and formal support systems. One of the most interesting findings was that the two
married women from this depression pattern perceived their husbands to be very resourceful
when it came to finding extra sources of income. For example, despite disabilities that kept him
from holding a permanent job, Jillian (age 40) was proud of her husband, who painted houses,
mowed lawns, and cleaned gutters. He also bought broken lawn mowers, computers, and other
household appliances, and then fixed and sold them. This perception of resourcefulness in their
husbands seemed to be associated with their perceptions of spousal support and a sense of
working together to persevere through their stressful situations.
“Stable Moderate” Depression
The women in the stable moderate depression pattern reported the fewest number of
primary stressors, but also reported the fewest number of primary strengths. Their resilience
processes differed greatly. Of all the depression patterns, the women in the moderate pattern
appeared to have a negative outlook on life. When asked if they were satisfied with life, they
were more likely to report having mixed feelings. Two of the women (ages 22 and 23) were new
mothers; their children were infants at the time of the first interview. It is possible their mixed
feelings could be attributed to postpartum depression. However, their outlook remained the

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same across all three waves, even when life circumstances appeared to improve. For example,
by the third year of the study, Louanne (age 22) had graduated from college with a registered
nurse degree and had a better paying job. She had reunited with her partner and planned to get
married. Interestingly, Louanne also reported a low level of social support for parenting. She
felt as if she was “doing this all alone,” even though she also reported that she got together with
friends regularly and received parenting advice from family members.
For one woman in the moderate pattern, cultural values may have played a role in her
outlook on life and her perceptions of social support. Tomasa (age 32) originally came to the
study as a migrant worker of Mexican origin. Her home was in a southern state, but she
migrated north each year with her immediate and extended families. By the second year of the
study she and the rest of her family had secured permanent jobs, so they no longer migrated. In
fact, Tomasa received training to become a certified nurse assistant, which was funded by her
employer. Despite new opportunities and an improving financial situation, Tomasa reported
feeling unhappy and often lonely, and she had a lower perception of social support. As she
explains:
It feels like when you migrate, you're closer to your family… Most of the time …
we’re all working in the same group together, and then even though we didn't
pick together, we were in the same field, you know?… And here, I just get to see
my mom like in the mornings before I go to work, just for her injection, and then
when I'm coming back from work, I stop by and give her her injection because
she's going in for work, so we hardly get to see one another.
Thus, for Tomasa, even though she still was able to see her mother briefly every day, it was not
enough to fulfill her need for family togetherness, a Hispanic cultural value. Missing her family
appeared to be associated with her sense of resilience.

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“High” Depression
The women in the high depression pattern consistently reported depression scores above
thirty each year. These women reported among the highest number of stressors. They each had
multiple health problems that seemed exacerbated by the frustration they felt when trying to get
their needs met through social service and health care agencies. Zola (age 45), for example, was
married with two children, and was extremely limited in her ability to participate in any activities
with her family. She had a “pile-up” of health problems, including emphysema, inflammatory
bowel disease, and carpal tunnel syndrome. Most stressing of all, she suffered from arthritis in
her neck and herniated discs in her spine which caused headaches and continuous neck, back and
leg pain, and which caused leg fatigue. Because of all her health problems, she had several
physicians that she needed to see on a regular basis; however the family car broke down, making
it difficult to get to her appointments. Despite all her health problems, Zola had difficulty
qualifying for disability benefits to help support her family, as she explains, “Because there's not
one doctor that will stand up in court and state it. They'll write it on paper but they won't state
it.” Neither Zola nor her husband could work (he also had disabilities), so they did not have the
money to fix their car. Their only sources of income were through welfare benefits. Having
Medicaid further exacerbated her problems because many physicians would not accept it.
Each woman included in this study with a high depression pattern was involved in
stressful relationships with someone close to her during at least one of the interviews, and had a
history of being abused by a previous partner. Two of them also were abused as children. All
three of the women reported that their children were currently experiencing behavior issues, such
as anger problems. One woman experienced so much depression and emotional strain that by the

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second year of the study she felt she could no longer be an effective parent. She relinquished
custody of her children to foster parents.
Based on these examples, it makes sense to evaluate these women and their families as
maladaptive. However, there were glimpses of resilience processes in their stories. For instance,
the women exhibited parenting strengths. They sought services for their children’s behavior
problems, and poured a lot of attention and time into them. One thing Nan (age 42) worked to
instill into her children was a value of serving others. She proudly reports:
My son will go and shovel my neighbor’s (driveway) because she's elderly, and if
he sees her pull up, he will drop what he's doing and run over and help her with
her packages. And see, they want to pay him, but I tell my kids it's about the
feeling that you get for helping that's more payment than what you could put
money on. So they like that. I'm just trying to put different values in them.
Even the woman who gave up custody of her children had their best interest in
mind. She felt protective of them and recognized she could no longer be an effective
mother. She took the initiative to find foster parents that she felt would be loving to her
children. In addition, when she talked with them, she felt it was important to give her
children permission to be happy with their new families.
Despite their frustrations with formal support systems and health issues, the women in
this pattern viewed other areas of life positively. They held on to hope that their lives would get
better, and sometimes even reported that they were very satisfied with life. They also were likely
to perceive their families as strong, as Zola and her husband report, “we ourselves have gotten
closer as a family…We've gotten stronger as a family.”
“Improving” Depression
The women in this depression pattern reported very high levels of depression in wave
one, and then much lower levels in the second and third waves. The high levels of depression

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they experienced that first year of the study were associated with a constellation of stressors
revolving around one significant negative life event. By the second interview, the women had
resolved the negative life event so that the issue was no longer an influence on their lives, and
the rest of the stressors seemed to diminish in importance or disappear. For example, in wave
one Kami (age 35) experienced severe financial strain, food insecurity, and health problems, but
this all seemed to revolve around a distressed marriage. Her husband did not contribute his
income to supporting the family: “When the baby needed diapers, he spent it on the truck and
car and I had to get the money somewhere.” By the second year of the study she had divorced
her husband, and the food insecurity and health problems resolved themselves. Her financial
strains were diminished because she obtained a job to support her family, and because she tapped
into her parents for social support.
Social support from parents, other family members, and neighbors and friends from the
community were very important for helping the women in the improving depression pattern to
actively resolve the main negative life event. These women built solid networks of support, such
that they had several sources to which to turn. Shakira (age 47), an African American single
mother with four children living at home and two adult children (not living at home), had an
extensive social network available to her on a daily basis, including her adult children, her
mother, extended family members, neighbors, and church members. This social support network
became very important when Shakira’s house burned down the day before Christmas one year.
There was an outpouring of giving from her support system and from local formal support
systems, such as the Red Cross and her children’s school, to find her a new place to live and to
replace necessities that were lost in the fire.

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The women in this pattern also maintained a positive perspective on life and parenting.
For example, Gabby was a 38 year old single mother in wave one who was raising three boys.
Her oldest son had developmental delays, along with behavior problems that caused legal
trouble. When Gabby was asked about any challenges to being a parent, she replied, “There’s
not really much challenges…with my oldest one, that’s not a challenge, that’s just part of life
that we had to get through…Right, it comes with the territory.” Rather than ruminating about
the difficulties of parenting a developmentally delayed child, she chose to view it as being a part
of the job that a parent works through.
The women also were likely to perceive their families as strong, close, and “there for
each other,” and they were likely to invest in themselves, by taking classes, going through
training programs for work, or by signing up for parenting educational programs. These women
actively pursued resources that helped them resolve the major negative life events that
contributed to their depression symptoms in the first year.
“Worsening” Depression
The women in the worsening depression pattern had no symptoms or mild depressive
symptoms the first year of the study, but experienced increasing symptoms each subsequent year.
Similar to the women in the high depression group, the women in this group had severe or
multiple health problems, which affected their ability to work, which also was associated with
financial strains. In addition, there was a high level of frustration or distrust with social service
systems. Trinity, a single, 39 year old mother of several children, explains her frustration when
she tried to attend a class that was run by a county social services agency on how to develop a
resume:
…they [the County] sent me to these classes which I thought were the biggest
joke…I said I'm here because I need help getting a job, I'm not here to talk about
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my feelings because my feelings aren't going to help me get a job. I want to know
how to write a really good resume. I want to know where I can get the skills that I
need …. ‘Well this is the way we run the program’ and I said it was a stupid
program…I said this is a waste of my time…I'm paying out day care so I can
come and learn something and nobody's teaching me anything.
Similar experiences among each of the women in the worsening depression pattern, along
with health and financial problems were associated with an escalation of depression symptoms
over time. The women in this pattern also reported the fewest sources of social support. Soliel
(age 29) provided an interesting example. During the second interview she described several
instances where others (including her current husband) provided both emotional and instrumental
support for her, but when asked about her level of satisfaction with the amount of support in her
life, she indicated not feeling well supported because she did not feel her children were well
supported: “You know, I think if they had more support I would feel more supported.” Upon
further elaboration, Soliel referred to relationship stresses she had been experiencing with her
current husband and with an ex-partner (her oldest son’s father).
Resilience processes leaned toward maladaptation for the women in the worsening
pattern. However, bonadaptive processes were evident, particularly the ability to maintain a
positive perspective. As Trinity explains, “I mean there's good days, there's bad days. But I
guess overall I'd say yeah...you just kind of keep looking the positives. I mean the kids are
clothed. I got a place to live. Got a car that runs most of the time. You know…I've got a
boyfriend, that's very happy.”
Another source of strength was the enjoyment they felt with being a mother. Soliel
expressed this sentiment well, “[I enjoy] getting on their level...Being a kid again with them!
[chuckles] … I love them. [laughs] I love them a lot. Um, I think I'm a really good mom, I'm
really protective, I know what they should and should not do. I know what we should and should
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not do.” It was important for the women to hold on to these positive aspects of being a parent to
help them endure the stresses in their lives.
“Erratic” Depression
Similar to women in the high and worsening depression patterns, primary stressors for
two of the women in the erratic pattern could be characterized by a pile-up of health problems
that prevented them from working and limited the activities they could do with their children.
Also similar to the high and worsening patterns, there seemed to be an interrelation between
multiple health problems, financial strains, and experiencing frustration with social service and
health care agencies. Increasing problems in one area seemed to exacerbate frustrations in the
other two areas. The women in the erratic pattern also were likely to have at least one stressful
relationship with someone close, which seemed to be associated with their depressive symptoms.
Although the stressors continued across all three years for the women in this pattern, they
all experienced a “dip” in their depression scores for wave two. That is, their depression scores
were high the first year, dropped to the mild depression range (below 16) in the second year, and
soared to above 40 in the third year. One possible explanation is that a family transition occurred
for two of the women between the first and second year. For instance in wave one, Abiona, an
African American, 34 year old mother with a partner and five children, was pregnant with her
sixth child. It may be that the anticipation of another mouth to feed, on top of health and
financial stresses and frustration with social services, made her feel further stressed, contributing
to her high depression score. By the second interview, Abiona and her family may have adjusted
financially and emotionally to the addition of a new family member. However, by the time of
her third interview, her back and other health problems worsened, and her relationship with her

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partner was tentative, because he moved out of the house. Her depression score spiked to high
levels.
The transition that occurred in Steph’s family was more unconventional. Steph and her
husband are older (49 years old). They have a ten year old daughter that they adopted, and other
grown children who no longer live with them. During the first year of the study, the couple
gained custody of two of their grandchildren because they were being neglected by their parents.
The uncertainty of raising two children with developmental delays, along with a myriad of
Steph’s health problems may be associated with her elevated wave one depression levels. By the
second year, the family had settled into a routine, and all three children (their daughter and the
two grandchildren) were in school all day. Steph felt as if she had gained some normalcy and
time with her husband, and she very much enjoyed raising her daughter and grandchildren. In
the third year, Steph lost custody of the grandchildren to her son, who had been released from
prison. She described a sense of loneliness and boredom with the children gone. The number of
health problems she experienced, along with her depression symptoms increased dramatically.
For one woman in this pattern the primary stressor seemed to be the relationship she held
with her parents. Sancha was a 26 year old single mother of one child, and she was of Mexican
origin. She was very proud that she had gained independence, and that she and her daughter
lived on their own. She enjoyed being a mother and spending time with her daughter.
Additionally, she loved working as a teacher’s aide, and was taking college courses to become an
elementary teacher. She had a sense of pride in accomplishing all of that on her own. However,
she had a difficult relationship with her parents. She relied on them to help take care of her
daughter when she had to work. They were happy to do this, but at the same time, they treated

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Sancha poorly. She indicates, “My parents try to help, but sometimes it's hard, they criticize...
they make a lot of fun of me. Even my dad does…[I] can't get away from them.”
It may be that her search for independence was perceived by her parents as a threat to the
Hispanic cultural value of family togetherness, and their criticism of her was as a way of exerting
control to keep her from straying too far. Another example of an attempt to control her is
evident from the third year (when her depression level spiked again):
“Um, I started um, dating someone they didn't like…So they started getting mad
at me and talking about me…And saying that she (her daughter) was here in the
house and seeing things that she's not supposed to and they started talking to
people. I found out by third sources that they were saying that they were going to
take her away from me.”
The second year “dip” in depression scores in Sancha’s case may be explained by her
engaging in new sources of social support. She gained new friends in her college courses and at
work. Additionally, she began jogging regularly with a friend. Engaging in new activities with
new friends seemed to boost her confidence, and combined with school successes, provided a
sense of accomplishment.

Discussion
The intent of this mixed methods research was to explore longitudinal depression patterns
identified among rural low-income mothers and to gain an understanding of individual and
family resilience processes within those patterns. Upon examining the higher level categories
(sources of stress and sources of strength) with their subthemes and comparing across depression
patterns, it became clear that even though the same themes were present across patterns, the
resilience processes looked very different for each pattern. The core variable, pictures of
resilience, emerged because it captured the essence of how resilience processes differed among
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each of the depression patterns. For each pattern, the interplay between the sources of stress in
the women’s lives and their sources of strength took on different characteristics. Such
differences and nuances about individual and family resilience processes are lost when data are
aggregated and de-contextualized.
Models of individual resilience (Luthar, Cicchetti & Becker, 2000) and Patterson’s
Family Adjustment and Adaptation Response (FAAR) Model (2002) propose that outcomes of a
resilience process result in either bonadaptation (positive adaptation) or maladaptation (negative
adaptation). However, because development is a continuous process, an individual’s or family’s
resilience outcome is relative to the point in time in which development is assessed (Patterson,
2002). That is, a person (or family) could emit evidence of maladaptive development in
adolescence, yet positive development ten years later. For the present study, any determination
of a resilient outcome was based on data from the third wave of interviews, the last point at
which rural mothers and their families were assessed.
For the women in the three maladaptive patterns, high, worsening, and erratic depression,
each source of stress appeared to exacerbate the others, which became overwhelming for each of
them. Space precludes including all the examples, however the overall experience of analyzing
transcripts from these three patterns gave the impression that these women were caught up in a
swirling vortex of unbearable stressors. Yet the women in these patterns were intentional in their
attempts to engage inner sources of strength (e.g., positive perspective, parenting strengths) and
tap into external sources (e.g., social support) in order to nurture their families. This metaphor of
a “swirling vortex” highlights the additive and interactive process nature of resilience, compared
with past studies that employed a pile-up-of-stressors metaphor (McCubbin & Patterson, 1983).

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This metaphor also provides a visual reminder of how difficult it can be for families facing
significant adversity to move forward.
The women in the two bonadaptive patterns, stable low and improving depression, and
their families also faced serious adversities in their lives, meeting the first criteria for a resilience
process (Hawley and DeHaan, 1996; Luthar, Cicchetti & Becker, 2000; Patterson, 2002a,
2002b). At the individual level, the mothers experienced both financial strains and adverse life
circumstances. Yet it also can be argued that the adversities that go along with financial strains
affected the whole family, as some of the families were food insecure and had difficulty paying
bills at points over the three years. Yet the sources of strength evident in these women and their
families could be characterized as tools that were activated intentionally by the women (and their
spouses or partners) to keep their families working together and moving in a forward direction.
Two of the women in the moderate depression pattern were qualitatively unique in their
resilience processes in that they reported the fewest and least adverse sources of stress as well as
the fewest sources of strength. The negative outlook on life they possessed may be more
consistent with theories of cognitive and interpersonal vulnerabilities to depression. Negative
cognitions may lead them to ruminate about negative events or stressors in their lives (Abramson
& Alloy, 2006; Gotlib & Joorman, 2010; Joorman, 2009), which may prevent them from
identifying possible solutions and moving forward. Their perceptions of having low levels of
support available to them, and “doing it all alone” may be consistent with dysfunctional
interpersonal schemas (Hammen, 2006; Hammen, Burge, Daley, Davila, Paley & Rudolph,
1995), and may explain why these women did not actively engage support networks to help offset their stressors.

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That their depression scores stayed in the moderate range over the course of the study is
puzzling, but it is possible that they had not encountered a negative life event traumatic enough
to trigger higher levels of depression (Levinson, 2009). It is also possible that the instrument
used to measure depression in community-based samples (the CES-D, Radloff, 1977) did not
capture enough depressive symptoms to adequately characterize depression in these women.

A Cultural Role in Resilience Processes
There was a cultural factor that seemed to play a role for the two women in the study who
were of Mexican origin. Family togetherness (familismo) is an important cultural value for
Latino families and has been shown to play a role in their sense of resilience (Parra-Cardona,
Bulock, Imig, Villarruel & Gold, 2006). However, family togetherness was a major source of
stress for both of these women, and for two very different reasons. Nostalgia for migrant life
when she worked with her family on a daily basis contributed to one woman’s sense of having
mixed feelings. The other woman felt constrained by her family and the level of control they
exerted over her and her daughter. She seemed to feel conflicted by a desire to pull away from
her family and feel independent, and a sense of duty and obedience to the cultural value. The
disparate stories of these two women around a central cultural value highlights the complexity of
influences cultural values can have on families, and how important they are to the resilience
process (Parra-Cardona, Bulock, Imig, Villarruel & Gold, 2006). This is consistent with Ungar’s
(2010) recommendation that culture and context play a central role in research and practice when
working with ethnic and minority populations.

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Limitations
This study offers a unique contribution to the literature by providing insight into the
contextual nuances that distinguished depression patterns among the rural low-income mothers
in this study, as well as resilience processes the mothers and their families developed; however it
is not without limitations. The family resilience literature suggests that shared meanings of
challenges and capabilities among family members are central to the concept of family
resilience. Although spouses/partners and children were sometimes present during the
interviews, there were only two cases (in this specific sample) in which a spouse or partner
contributed information to the interviews. Information obtained from other household members
may have provided a better means for observing the processes by which the sample families
created shared meanings and situational appraisals. Their participation would have provided
better insight into the effect of the mothers’ depression on the family system.
Data on depression for this study was obtained from a community-based sample using a
self-report instrument (the CES-D, Radloff, 1977). While a two of the mothers reported that they
were taking medication for depression, little is known about the nature of the diagnosis and the
lifetime history of depression among the women in the sample. For instance, among the women
who did report that they were taking medication, there is no information on who made the
diagnosis (primary physician or psychiatrist), how they made the diagnosis (e.g., structured
interview versus self-report), or the history and course of their depression (e.g., age at first onset,
whether they were currently in a major depressive episode or in recovery, or average length of
depressive episodes). Therefore, the findings of this study may not generalize to populations of
clinically diagnosed depression.

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Last, purposive sampling including three extreme cases for the qualitative analyses
enabled rich exploration and shed light on characterization of the depression patterns; however
the small sample within each pattern may have limited theoretical saturation. Future studies
could expand such investigations to include larger samples within each pattern. Conversely,
future studies could also focus sampling frames to explore contextual nuances of depression
patterns that may be identified among other populations, such as fathers, urban populations,
ethnic and minority populations, and specific age groups. Despite the stated limitations, the
compelling findings using mixed methods and a longitudinal depression categorization have
implications for further studies with larger samples.
Implications for policy and practice
It is apparent from the findings that having a perception of parental and family strengths
is important for resilience processes. Perceived social support plays a crucial role in that women
and families experiencing bonadaptation actively tapped into strong social support networks,
while those experiencing maladaptation perceived themselves and their families as having little
to no access to social support. In addition, at least one of the mothers indicated a need for
practical job training. The findings have implications for therapeutic and educational
collaborations that focus on parenting, marital relationships and general relational skills that will
empower mothers with depression vulnerabilities to build healthy attachment cognitions and
healthy social support systems. Inclusion of family members also is important, particularly
spouses or partners, in order to strengthen relational skills and adaptability within the family
system. Clinicians undertaking such a task must possess a comprehensive understanding of the
complex nature of depression and the way it plays out in families. In addition to relational

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aspects, educational programs should have practical applications that will equip low-income
mothers to write a resume and prepare for job interviews.
From a social and health services standpoint, programming and policy that places cultural
and contextual understanding at the center of service delivery (Parra-Cardona, Bulock, Imig,
Villarruel & Gold, 2006; Ungar, 2010) is important for identifying depressed individuals and
families experiencing multiple, interrelated stressors. Service providers and stakeholders are
needed who understand that depression and multiple health problems compound financial stress
and exacerbate strains in relationships and family functioning. Physicians sensitive to such
issues are helpful when they are willing to complete necessary forms and advocate in court to
help connect patients with needed resources (e.g., disability determination forms and hearings).
In addition, family advocates placed within health organizations can help individuals and
families establish networks of formal support.
Finally, policies for determining eligibility for supplemental support and for social
security disability should consider the complex relationship between depression and multiple
medical problems. Many of the women in the high, worsening and erratic patterns had difficulty
qualifying for social security, despite their debilitating pile-up of medical problems and severity
of depression. The findings from this study are consistent with Moussavi, Chatterji, Verdes, and
Tandon, et. al. (2007), who used data from the WHO World Health Survey to determine that
depression had the largest effect on worsening health scores than other chronic conditions tested.
That is, compared to angina, arthritis, asthma and diabetes, “the comorbid state of depression
incrementally worsens health compared with depression alone, with any of the chronic diseases
alone, and with any combination of chronic diseases without depression” (p. 851). These results
held across countries and across demographic characteristics. The findings confirm that

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regardless of causal direction, it is important to consider health problems and the history of
depression when disability determinations are made.
Conclusions
A strength of the study was the longitudinal and mixed method design, which provided a
methodological structure for analyzing both quantitative and qualitative data in relation to
depression. The findings provided valuable insight to the complex nature of depression and how
patterns of depression can play out in the context of rural low income families. Another strength
was the analysis and organization of the data according to longitudinal depression patterns. This
allowed for unique nuances of resilience processes within each depression pattern to be
observed, both at the individual and family levels. The additive and interactive nature of the
sources of stress suggested a metaphor of a “swirling vortex”, which was especially compelling
for women in the high, worsening and erratic patterns. On the other hand, the ability of many of
the mothers to actively tap into sources of strength must be emphasized. Additionally, the role
that culture played among the two women of Mexican origin brought forth new insight into an
important cultural value, familismo, and its relationship with resilience. Together, these findings
highlighted nuances of resilience processes that help to build upon a resilience framework

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CHAPTER 4
STUDY 2: INVESTIGATING RURAL LOW-INCOME
MOTHERS’ LONGITUDINAL DEPRESSION PATTERNS
USING A RISK AND RESILIENCE FRAMEWORK
Abstract
A mixed methods, longitudinal design and risk and resilience and ecological models were used
to explore the ways risk and protective factors organized themselves according to six depression
patterns for eighteen rural low-income mothers. MANOVA and MANCOVA procedures
provided insight into how the risk and protective factors organized themselves amid depression
patterns. Mothers in the high, worsening, and erratic patterns experienced more health problems,
child health problems, financial strain and food insecurity. Mothers in the low and improving
patterns experienced fewer risk factors, and reported a higher sense of parental confidence and
social support. Qualitative analyses provided further explanation and support for the quantitative
findings, and provided insight into the relationships among the risk factors and the interactive
ways the mothers tapped into protective factors. The findings highlight the complexity of
resilience processes in the face of maternal depression among rural low-income women.
Implications for policy and practice are discussed.

Keywords: maternal depression, health, financial strain, resilience, social support, parenting

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Introduction
Depression is a devastating disease, affecting the daily context of personal and family
life. Much has been learned about the causes or contributing factors of depression in men and
women (e.g., Ross & Huber, 1985; Ross & Mirowsky, 1989; Mirowsky & Ross, 1990; and
Turner & Lloyd, 1999). More recently, researchers have been able to illuminate family
relationship dynamics specifically related to depression in mothers (Brown, Brody & Stoneman,
2000; Smith & Howard, 2008; Gross, Shaw, Burwell & Nagin, 2008; and O’Brien Caughy,
Huang & Lima, 2009). The field has increasingly focused on the correlates and detrimental
effects of maternal depression. Such interest is justified when considering the far-reaching
consequences experienced by children and families when mothers suffer from depressive
symptoms.
However, a better contextual understanding of maternal depression is needed and can
emerge when looking longitudinally at patterns of depression and their influences on personal
and family life contexts. The human ecological approach provides a framework for that
contextual understanding (Bronfenbrenner, 1986). Using mixed methods, this study considered
specific components of the Process-Person-Context-Time (PPCT) model (Bronfenbrenner, 1986,
1989, 1994, and as discussed by Tudge, Mokrova, Hatfield & Karnik, 2009). For example,
quantitative analyses explored characteristics of the mothers that influence their depression
patterns, such as the number of health problems they suffer, their sense of parental confidence,
and their outlook on their family’s financial situation. Also explored were characteristics of the
family context that influence rural mothers’ depression patterns, such as the number of child
health problems and the degree to which a family is food insecure. Qualitative analyses further
explored individual and contextual characteristics that reveal proximal processes within the

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family microsystem and processes between rural mothers, their families and other systems
(mesosystem).
Through a risk and resilience lens, components of the PPCT model (individual and
contextual characteristics and proximal processes) were conceptualized as risk and resilience
factors. Resilience is defined as a “dynamic process encompassing positive adaptation within the
context of significant adversity” (Luthar, Cicchetti & Becker, 2000, p. 543).
Risk factors refer to adversities individuals and families experience that pose threats to
positive development (Masten & Powell, 2003). Such risks may exist within the individual (e.g.,
physical disabilities, mental illness) or in the developing individual’s environment (e.g., poverty,
divorce, abuse). Conversely, resilience mechanisms are factors and processes that protect
individuals and families from adversities. Protective factors may exist within an individual (e.g.,
parenting strengths) or in the individual’s environment (e.g., social support).
Common Risk Factors of Maternal Depression
Depression has been characterized as a constellation of behaviors and symptoms that
affect physical abilities (e.g., fatigue, decreased appetite), emotions (e.g., feelings of guilt or
worthlessness), and cognitive abilities (e.g., difficulty with concentration,) (Gotlib & Joormann,
2010). According to Gotlib and Joormann, “depression is primarily a disorder of emotion
dysregulation and sustained negative affect” (p. 287). Research has consistently shown that
women are more likely to suffer from depression than men (Ross & Mirowsky, 1989; Kessler et
al., 2003), particularly women of child-bearing ages (18-45 years old) (Substance Abuse and
Mental Health Services Administration, 2010).
Many risks of maternal depression have been identified, such as socioeconomic status,
economic strain and poverty, (Brown, Brody & Stoneman, 2000; Casey, et.al., 2004; Coiro,

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2001; Dennis, Parke, Coltrane, Blacher, & Borthwick-Duffy, 2003), and food insecurity (Olson,
Anderson, Kiss, Lawrence, & Seiling, 2004; and Olson, 2006). However, the literature paints a
complex picture of the relationship. For example recurrent exposure to poverty during critical
stages of childhood and adolescence is linked with depression in adolescence and early
adulthood (Najman, Mohammad, Clavarino, Bor, O’Callaghan & Williams, 2010). Poverty also
has been shown to be associated with depression among women, such that changes in economic
status bring about changes in depression (Dearing, Taylor, & McCartney, 2004). Recent
longitudinal studies aiming to untangle the causal relationship support social causation models
(Eaton, Muntaner, Bovasso & Smith, 2001; Monroe, Slavich & Georgiades, 2009; Simmons,
Braun, Charnigo, Havens & Wright, 2007). According to social causation models, chronic
poverty, limited access to resources and supports, and family and life stressors place individuals
at higher risk for health and mental health struggles (Simmons, Braun, Charnigo, Havens &
Wright, 2007). In many of these studies family or household income was used to measure
poverty. However, other studies have revealed a weak association between income and
depression and have found instead that the relationship is mediated by individuals’ subjective
perception of economic strain and material loss (Dennis, Parke, Coltrane, Blacher, & BorthwickDuffy, 2003; Ennis, Hobfall & Schroder, 2000; Hovey & Magaña, 2002; Ross & Huber, 1985).
The relationship between depression and health problems is also complicated. It is often
assumed that health problems are risk factors for depression. However, as Freedland and Carney
(2009) point out, chronic health problems in most people begin to appear later in life, whereas
depression peaks in adolescence and early adulthood. Complications also arise when examining
correlations between depression and specific health problems, such as diabetes, arthritis, stroke,
heart attack, and so forth. It appears that painful conditions, such as arthritis and migraine

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headaches, are stronger predictors of depression than other diagnoses (Freedland & Carney,
2009). However, the causal direction of the relationship between depression and other health
problems can be difficult to assess.
Common Protective Factors Associated with Maternal Depression
A sense of confidence in one’s parenting abilities has been found to have mediating
effects in regard to several parenting stressors (e.g., depression) and their relationships to child
outcomes. In their study, Ontai, Sano, Hatton and Conger (2008) used parental confidence as
their dependent variable and found that rural low-income mothers’ parental confidence was
directly influenced by the presence of parent and child health problems. The relationship was
mediated by the presence of parental support for mothers with partners, but not for single
mothers. That is, the strength of the influence of family health problems on parental confidence
was decreased when rural mothers were married or had a partner living in the home. It appears
that for the daily hassles of parent and child problems, having another adult in the home helps
alleviate the strains brought on by those daily hassles.
Parental confidence also can be a moderating variable. For example, Knoche, Givens &
Sheridan (2007) found that adolescent mothers with high levels of depression but whom also had
a high sense of parental competence had children who scored higher on cognitive tests. This is
in comparison to adolescent mothers reporting high levels of depression and a low sense of
parental competence, whose children scored lower on cognitive tests. A sense of parental
confidence also is an important mediator for the influence of parents’ personality characteristics
(e.g., extraversion and agreeableness) and their parenting characteristics (e.g., warmth, overreactivity) (de Haan, Prinzie & Dekovic, 2009). In another study, Jackson and Scheines (2005)
found that parent self-efficacy beliefs were a mechanism which mediated the effects of maternal

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employment on parenting behaviors and child outcomes. Thus the research points to the
importance of parental confidence to family relationships and functioning. Parental confidence
can be a protective factor for families, and was shown in the research discussed to be an
important process variable.
Social support is another construct that has been found to be protective for mothers with
depression (Brown, Body & Stoneman, 2000; Hammen, 2006; Islam, 2004; Richards,
Manoogian, Seiling & Bird, 2002). Social support was reported earlier to mediate the
relationship between family health problems and parental confidence among rural low-income
women (Ontai, Sano, Hatton and Conger, 2008). Similarly, Bulock (2004, 2007) found that
parental social support (that is, social support specific to the parenting role) mediated the
relationship between parental confidence and depression among rural low-income women.
Further, social support is a concept that links the resilience and depression literature.
Important sources of social supports for individuals include close and caring relationships with
parents and other competent adults, associating with prosocial peers, and connections to positive
community assets such as clubs, religious groups and libraries (Masten and Powell, 2003).
Similarly, several models used in the family resilience literature (McCubbin & Patterson, 1983;
Patterson, 2002) point to the importance of families tapping into social support resources both
inside and outside of the family.
Hypotheses
For this study, mothers from the Rural Families Speak study were divided into six groups
which reflect the longitudinal patterns of their depression experiences. The depression patterns
are described more fully in the next section, but include stable low, stable moderate, high
depression, worsening depression, improving depression and erratic depression. Comparisons

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were made across patterns to explore ways in which risk and protective factors may work
uniquely within each depression pattern. Five research hypotheses for this study are presented:
H1: Mothers with low levels of depression across all three years will have fewer risk
factors than mothers in the other depression patterns.
H2: Mothers whose depression was high all three years, or whose depression worsened
over the course of the study, will have more risk factors than mothers in the other depression
patterns.
H3: Food insecurity and a higher number of health problems will be risk factors for
mothers in the high and worsening depression patterns.
H4: The relationship between monthly income and depression will be mediated by
mothers’ perceptions of economic strain for the whole sample.
H5: The relationship between mothers’ sense of parental confidence and depression will
be mediated by mothers’ perceptions of parental social support for the whole sample.
Consistent with the exploratory nature of this study, post hoc analyses will examine
differences between the depression patterns for each of the dependent variables. Qualitative
themes will provide contextual explanations to further support quantitative findings.
Methods
Data from the Rural Families Speak project were analyzed for this study. Rural Families
Speak was a multiple state research project that employed a multidisciplinary, longitudinal, and
mixed methods approach to develop an understanding of the challenges and complexities faced
by rural low-income families within the context of welfare reform. See Bauer (2004) and Bauer
and Dolan (2011) for more background information about Rural Families Speak project and
participants.

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Sample
A purposive sample was selected for the Rural Families Speak study due to the difficulty
in obtaining a consistent across state random sample of rural low-income, highly mobile families
Most states recruited their participants through food programs or other agricultural extension
education programs for low-income families. To be included in the study, each family had to
have at least one child 12 years old or younger living in the home. Families also had to be
eligible for, but not necessarily receiving, Food Stamps or the Supplemental Nutritional Program
for Women Infants and Children (WIC), or have a poverty ratio less than 200% of the poverty
level limit. The sample included participants from four states in the Eastern region, five in the
Central region, two in the Southern, and four in the Western region. Compared to low-income
rural families in the nation, the Rural Families Speak sample had a higher proportion of rural
Latino(a) families (17%), a lower proportion of White families (69%), and a lower proportion of
Black families (6%). Native American families (n=2, 0.9%) were not targeted for recruitment
due to complicated circumstances regarding tribal benefits and services.
The sample from the first wave of the Rural Families Speak project included 433 mothers
for wave one, 326 for wave two, and 271 for wave three. The quantitative portion of the present
study was limited to mothers who participated in all three waves of data collection so that
longitudinal depression patterns could be studied (N = 233). Further, eight mothers were missing
100% of items from two important variables (parental confidence and parental support). Close
inspection of the depression patterns for the eight mothers revealed that there was no pattern to
their missing data in relation to depression. Four of the mothers were in the “low” depression
pattern, one was in the “moderate” pattern, one was in the “high” pattern, and two were in the
“erratic” pattern. It was determined to eliminate the eight cases to prevent a loss of statistical

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power, rather than using listwise deletion in analyses (Schlomer, Bauman, & Card 2010). This
brought the sample for the present study to N = 215. In the remaining sample, person mean
substitution was used for the depression measure for all three waves when cases were missing
less than 20% of the items (Downey & King, 1998; C. F. Page, personal communication,
February 16, 2004).
Table 4.1 compares the sample from the first wave to the current sample of mothers.
There are differences in ethnicity and education level when comparing the two samples. The
2

current sample includes a higher percentage of mothers who are non-Hispanic White ( (6, 410)
2

= 18.88, p < 0.05) and who are more educated ( (6, 412) = 44.11, p > 0.05). There are no
significant differences between the two samples in terms of depression (t (384) = 0.289, p =
0.773), age (t (408) = -1.20, p = 0.106), or annual income (t (411) = -0.895, p = 0.371).

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Table 4.1. Characteristics of Rural Families Speak Wave 1 Sample and Present Study Sample
Dropped from RFS
(N = 198)

Current Sample at
Wave 1 (N = 215)

W1 Depression Score – range 18-59; mean (SD) 17.6 (11.7)

17.3 (11.1)

Demographic Variables
Participant’s Age – Mean (SD)
Annual Income – Mean (SD)

29.4 y.o. (7.49)
$15,044 (10,681)

30.6 y.o. (7.45)
$ 15,962 (10,172)

Ethnicity
Non-Hispanic White
Hispanic/Latina
African American
Native American
Multi-racial
Other

56.3%
28.9%
10.7%
1.5%
4.0%
0.5%

71.8%
15%
7.0%
0.9%
5.0%
0.5%

18.3%
27.4%
25.9%
9.6%

3.3%
15.3%
30.2%
17.2%

16.8%
2.0%
0.0%

29.3%
3.7%
0.9%

Education
8th grade or less
Some high school
High school or GED
Specialized technical, business, or
vocational training after high school
Some college, including AA
College or university graduate
Graduate degree
Data Collection

The project collected three waves of quantitative and qualitative data from 24 counties in
14 states. Protocols for each wave were approved by research ethics boards for each
participating site, and participants provided informed consent for each wave. The project
collected three waves of quantitative and qualitative data over a five year time period from 24
counties in 14 states. Trained interviewers in each state conducted interviews face-to-face with
the woman in the family for about two hours using a semi-structured protocol, were taperecorded and later transcribed for data analysis. Quantitative data included demographic,

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financial and employment information, as well as information on the number of health and
mental health problems in the family and their access to health care. Instruments included the
Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977); the Parenting
Ladder (Richards, 1998); and the Core Food Security Module (Hamilton et al., 1997).
Qualitative protocol included open ended questions designed to gain more detailed
information about participants’ responses to the quantitative questions. For instance, when
asking mothers about their employment status, interviewers also would ask whether anything or
anyone made it more difficult for the mother to work. Likewise, after completing the CES-D and
the Parenting Ladder, interviewers would ask mothers to elaborate on items of interest. For
example, mothers were asked to rate themselves on the Parenting Ladder in terms of “your
overall satisfaction with the amount of support in your life,” after which interviewers asked the
mothers to explain why they rated themselves that way.

Measures
Maternal depression was measured using the Center for Epidemiologic Studies
Depression Scale (CES-D), which was designed to measure symptoms of depression in the
general public (Radloff, 1977). Participants were asked to rate how often they experienced
certain feelings within the last week. Responses ranged from “rarely or none of the time” (coded
as 0) to “most or all of the time” (coded as 3). Sample items included: “I could not shake the
blues,” “I had crying spells,” and “I felt depressed.” Responses are summed, and total scores
range from zero to 36. Studies testing validity have shown that the CES-D is highly correlated
with other measures of depression (Radloff, 1977). The 20-item inventory has a reported high

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internal reliability, with Cronbach’s alpha of 0.82 (Radloff, 1977). Cronbach’s alpha for the
current sample for wave one (N = 215) is 0.89.
The sample was divided into six depression patterns, which was done in two steps. For
the first step, mothers’ depression scores for each year of data collection were coded into four
categories according to Seligman’s recommendation (1998): nondepressed, and mildly,
moderately and severely depressed.
Table 4.2 reflects the changes that occurred in depression over time in an aggregated
sense. When looking at changes across the whole sample, it appears that the number of mothers
with no depression increased, and the number of mothers with moderate or severe depression
decreased.

Table 4.2. Numbers And Percentages Of Mothers In Each Depression Category For Each Wave
Depression Category
Nondepressed
Mildly depressed
Moderately depressed
Severely depressed

Depression score
range
0-9
10-15
16-24
>24

Wave 1
n = 215 (%)
59 (26)
51 (23)
62 (28)
51(23)

Wave 2
n = 215 (%)
83 (37)
61 (27)
49 (22)
30 (14)

Wave 3
n = 215 (%)
85 (38)
52 (23)
42 (19)
44 (20)

The above step allowed for comparisons of the levels of depression across all three years
for the sample. However, this snapshot is more complicated when comparisons are made across
all three years for each mother. Such comparisons led to the emergence of longitudinal
depression patterns. That is, upon examining depression at each wave for each mother, it
became clear that depression levels varied greatly for many mothers each year.
Therefore, the second step involved placing each mother into one of six longitudinal
depression patterns:

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

Stable low pattern consisted of mothers who reported depressive symptoms consistent
with categories one and two (nondepressed and mildly depressed), and who remained in
those low categories across time (low  low  low) (n = 75).



Stable moderate pattern consisted of mothers who reported depressive symptoms in the
moderately depressed range over time (mod  mod  mod) (n = 25).



High depression pattern consisted of mothers whose depression remained in the severely
depressed category all three waves (high  high  high) (n = 14).



Improving depression consisted of mothers who experienced high levels of depression
the first wave, but reported much lower symptom levels by the second and third waves
(high  low  low) (n = 48).



Worsening depression consisted of mothers experiencing few depressive symptoms
during the first wave, but more severe depressive symptoms over the next two waves
(low  high  high) (n = 34).



Finally, for some mothers the pattern was erratic, such that the reported symptom levels
changed dramatically each year of data collection (high  low  high) (n = 28).

Risk Factors
Perceived economic strain is conceptualized as a rural mother’s subjective perception
that her family’s economic situation has worsened or improved. It is used as a covariate in these
analyses because it is highly correlated with food insecurity, r(203) = -0.307, p < .01.
Surprisingly, it is not significantly correlated with average monthly income for the current
sample, r(214) = 0.088, p = 0.200. Operationally, mothers’ perceived economic strain is a oneitem measure Likert scale with responses coded from one-to-five. The participants were asked
the extent to which they thought their economic situation had changed compared to the previous
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year. Responses ranged from “gone down a lot” (1) to “improved a lot” (5). The variable was
reverse coded for this study so that higher scores meant higher sense of economic strain.
Mothers’ number of health problems was measured using the adult health surveys
developed by the Oregon State University Family Policy Program (Richards, et al., 2000). The
items were compiled from medical screening forms typically used by health care providers.
Each condition was coded as (1) if the respondent indicated it was present, and responses were
summed.
The average number of child health problems was measured using child health surveys
similarly developed by the Oregon State University Family Policy Program (Richards, et al.,
2000). Total health problems were summed for each child, and then totaled for all children in
the family. To account for family size, the family’s average number of child health problems was
computed and used in this study. Average scores ranged from zero to 11.6.
Average monthly income was calculated by adding and then averaging all of mothers’
sources of income (excluding food stamps), including their wages and wages of spouse or
partner, overtime, social security disability, retirement or pensions, unemployment, worker’s
disability, child support, and temporary assistance to needy families (TANF/MFIP).
Food insecurity was measured using the Core Food Security Module (Hamilton et al.,
1997), which has been found to have good reliability, with a Cronbach’s alpha coefficient of 0.81
for homes with children. In addition, responses to items have been found to be consistent across
diverse populations, including racial and ethnic minorities, and scale scores are significantly
related to the Poverty Income Ratio in the expected ways, indicating validity. This is a
constructive scale, with final scores calculated by the Rural Families Speak - New York team. A
higher score on the scale means a family is more likely to be food insecure.

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Protective Factors
Marital status of the mother is a demographic measure reflecting family structure.
Possible responses to this item are single, married, living with partner, divorced, or separated.
Parental confidence is conceptualized as participant’s subjective feelings about her
abilities, or role fulfillment, as a parent. Parental confidence is one component of “The Parenting
Ladder” which is a measure constructed by the Oregon State University Family Policy Program
(Richards, 1998). Each item is scored on a seven point scale in terms of where the participant
would put herself on the ladder. A score of 0 means the person places herself at the lowest point
on the ladder, with 6 as the highest point. Items for the parental confidence portion ask
participants where they would put themselves on the ladder in terms of, for example: a)
knowledge of how children grow and develop; b) confidence that one knows what is right for the
child; and c) success in teaching the child how to behave. Cronbach’s alpha has been shown to
be 0.70. Cronbach’s alpha for this sample was 0.68 (N = 215).
Parental support is conceptualized as social support that is specific to supporting
mothers in their parenting role.

However, it is used in these analyses as a covariate because it is

significantly correlated with parental confidence, r(211) = 0.439, p < .01. Operationally,
parental support is the other component of “The Parenting Ladder.” This six-item portion asks
participants about support they get from others for their parenting role. Items for the parental
support portion ask participants where they would put themselves on the ladder in terms of, for
example: a) other parents to talk to; b) someone to help in an emergency; and c) someone to offer
helpful advice or moral support. Cronbach’s alpha has been shown to be .86, and was 0.82 for
this study (n = 215).

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Analysis Strategy
The data for the larger Rural Families Speak study were collected consistent with a
concurrent triangulation design (Creswell & Plano Clark, 2007; Creswell, Plano Clark, Gutmann,
& Hanson, 2003) in which the quantitative and qualitative data were collected at the same time,
however, integration for this particular study occurs at the analysis stage in which “statistical
trends are supported by qualitative themes” (Creswell, Plano Clark, Gutmann, & Hanson, 2003,
p. 233). The wave one data set was used for the quantitative analyses. Using quantitative data
from all three waves would have been preferable; however there were more missing data in the
second and third waves. Therefore, it was decided to use wave one data to have the maximum
amount of data available to conduct these exploratory analyses.
First, comparisons were made in order to characterize each variable by mothers’
longitudinal depression pattern. Pearson’s chi-square was used to test relationships between
nominal demographic variables and mothers’ depression patterns, and MANOVA and
MANCOVA procedures were conducted to explore relationships among the remaining interval
and ratio level variables and mothers’ depression patterns. Because of the exploratory nature of
the study, post hoc analyses were conducted to learn how distributions for each variable differed
by depression pattern.
Next, three cases from each of the depression patterns (n = 18 cases) were selected for
qualitative analyses. Extreme cases in each pattern were selected. Guided by the research
questions, hypotheses and conceptual framework, comparing and contrasting multiple cases
within each pattern can “strengthen the precision, the validity, and the stability of the findings”
(Miles & Huberman, 1994, p. 29). Thus, for each pattern, cases were selected based on extreme
depression scores Mothers with consistently lowest depression scores were selected for the low

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depression pattern. Mothers with the consistently highest depression scores were selected for the
high pattern. For the improving, worsening and erratic patterns, mothers were selected for the
extreme values in depression scores across all three waves, according to their pattern. In
addition, where possible, cases were selected from different states for each pattern to vary
location. The worsening depression pattern is the only pattern in which more than one case was
from the same state.
For each case, the mothers’ transcripts for all three years were analyzed. Thus a total of
54 transcripts were coded and analyzed (three mothers X six depression patterns X three
transcripts) using MaxQDA software (Belous, 2007). Theoretical thematic analyses were
conducted, using the quantitative variables as theoretical guides. However, analysis was at the
latent level, rather than the semantic level, in order to examine the underlying differences
between and conceptual nuances of the variable indicators among the depression patterns (Braun
& Clarke, 2006). The first step involved familiarization with the data by reading and re-reading
the cases and creating memos about initial ideas about the relationship between the qualitative
data, the quantitative data, and the theoretical framework. Open coding was conducted next to
create initial codes, followed by organizing codes into potential themes related to the quantitative
variables. The final steps involved an iterative process of reviewing themes in relation to the
codes, in relation to the depression patterns, and in relation to the whole data set, followed by
refining of themes and “the overall story the analysis tells” (Braun & Clarke, 2006, p. 87). The
objective of the qualitative analyses was two-fold: 1) to gain an understanding of the context in
which these patterns occur, specifically the ways in which risk and resilience factors and
processes differed across patterns and; 2) to provide clarification, support, or a fuller explanation
of quantitative findings.

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Results
Table 4.3 presents the characterization of demographic variables with mothers’
depression patterns. A univariate analysis of variance revealed that there are no significant
differences among the depression patterns in terms of mothers’ age, (F (5, 208) = 0.889, p =
2

0.49), or education levels, ( (5, 213) = 1.86, p = 0.87). There were a higher percentage of
Hispanic/Latina mothers in the low depression pattern compared to White and African American
mothers, and a higher percentage of African American mothers in the moderate and improving
depression pattern compared to White and Hispanic/Latina mothers. Overall the chi-square
2

value for these comparisons was  (15, 215) = 14.57, but not statistically significant at the 0.05
level (p = 0.48). Similarly, the overall chi-square value for comparisons between mothers’
2

marital status and depression patterns was  (20, 215) = 14.76, but did not achieve statistical
significance (p = 0.79). However, one can see that mothers who were in the low and improving
depression patterns were more likely to be married or living with a partner, while mothers in the
high and worsening depression patterns were more likely to be single, divorced or separated.
Mothers with a moderate pattern were likely to be living with a partner, and mothers with an
erratic pattern were equally likely to be single, married, or divorced.
Because of the non-significant relationships for age and education, these variables are not
included in the MANOVA model. Collapsing categories for ethnicity and marital status did not
increase cell sizes or help make the cells more even. This is likely due to the number of
depression patterns and small study sample. Therefore, these two variables also are not included
in the MANOVA model.

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Table 4.3 Demographic Variables Characterized By Rural Mothers’ Depression Patterns
Low
n = 75
% (n)
31.2 (8.2)

Age
M (SD)
Education
High school &
less
More than high
school
Ethnicity
White
Hispanic/Latino
African
American
Other
Marital status
Single
Married
Living
w/partner
Divorced
Separated

Moderate
n = 25
% (n)
29.1 (6.8)

High
n = 14
% (n)
31.6 (7.4)

Improving
n = 48
% (n)
29.6 (7.0)

Worsening
n = 34
% (n)
30.2 (7.0)

H-L-H
n = 27
% (n)
32.6
(7.1)

30.6 (22)

9.7 (7)

6.9 (5)

26.4 (19)

16.7 (12)

9.7 (7)

34.0 (48)

12.1 (17)

5.7 (8)

19.9 (28)

15.6 (22)

12.8 (18)

30.7 (47)
40.6 (13)
33.3 (5)

10.5 (16)
12.5 (4)
26.7 (4)

7.8 (12)
0
0

20.9 (32)
21.9 (7)
26.7 (4)

16.3 (25)
15.6 (5)
6.7 (1)

13.7 (21)
9.4 (3)
6.7 (1)

40.0 (6)

0

6.7 (1)

33.3 (5)

20.0 (3)

0

31.5 (17)
39.0 (32)
22.9 (8)

11.1 (6)
7.3 (6)
17.1 (6)

7.4 (4)
4.9 (4)
5.7 (2)

20.4 (11)
23.2 (19)
34.3 (12)

16.7 (9)
12.2 (10)
14.3 (5)

13.0 (7)
13.4 (11)
5.7 (2)

31.0 (9)
33.3 (5)

13.8 (4)
13.3 (2)

6.9 (2)
6.7 (1)

17.2 (5)
6.7 (1)

17.2 (5)
33.3 (5)

13.8 (4)
6.7 (1)

Table 4.4 presents the means and standard deviations of the dependent variables
according to mothers’ depression patterns. The covariates were included in Table 4.4 to show
distribution of those variables among depression patterns. A one-way MANOVA was conducted
to test the model with all of the dependent variables (including the covariates, parental support
and economic strain), and revealed a multivariate main effect for mothers’ depression patterns,
2

Wilks’  = 0.561, F (35, 793.27) = 3.34, p < .05, partial  = 0.109. Power to detect the effect
was 1.000. A Box’s test of equality of covariance matrices approached significance, suggesting
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differences among the depression patterns in the covariance matrices, Box M = 192.49, F (140,
13481) = 1.20, p = 0.058. Because of the exploratory nature of the study, post hoc analyses were
conducted to determine distributions for each variable differed by depression pattern. These
results and ANOVA results are described below, but first, due to the Box’s test, it is important to
explain results of a MANCOVA that was run to control for the effects of parental support and
economic strain. This test revealed that the overall main effect for mothers’ depression patterns
remains significant, but the F and partial eta squared values are decreased, Wilks’  = 0.722, F
2

(25, 699.89) = 2.56, p < .05, partial  = 0.063, and power to detect the effect was .994. Thus, it
appears that the covariates may play a mediating role in the relationship between the depression
patterns and the dependent variables. It is important to consider these results when interpreting
the univariate and post hoc results.
Given the significance of the overall test, the univariate main effects were examined.
Maintaining an experiment-wise alpha rate of 0.05 required that it be divided by seven (for seven
dependent variables X one independent variable) in order to obtain an acceptable confidence
level for each test to decrease the probability of a Type I error (Howell, 2002). Therefore, the
alpha level is set to p < 0.007 for each of the univariate analyses. The depression patterns have
significant univariate main effects on six of the dependent variables; however, there was not a
significant univariate effect on monthly income:
2

 Health problems: F (5, 194) = 9.0, p < .001, partial  = .20, power = 1.000
2

 Child health: F (5, 194) = 7.5, p < .001, partial  = .16, power = .999
2

 Monthly income: F (5, 194) = 2.1, p = .07, partial  = .05, power = .687
2

 Food insecurity: F (5, 194) = 9.2, p < .001, partial  = .20, power = 1.000
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2

 Economic strain: F (5, 194) = 3.5, p < .007, partial  = .08, power = .914
2

 Parental confidence: F (5, 194) = 6.3, p < .001, partial  = .14, power = .996
2

 Parental support: F (5, 194) = 7.2, p < .001, partial  = .16, power = .999
Levene’s statistics for the dependent variables are not significant for parental confidence,
child health problems, monthly income, economic strain, or parental support, but are significant
for mothers’ health problems and food insecurity, suggesting that equal variances should not be
assumed. Further, because of the uneven cell sizes, especially for the stable high depression
pattern, the Games-Howell procedure for unequal variances was used for post hoc analyses
(Howell, 2002).
The post hoc analyses are of specific interest in order to explore differences among the
depression patterns, and Table 4.4 indicates that significant differences were found. Many of the
values for the high depression pattern were substantively different from values for the other
depression patterns, but did not achieve statistical significance, possibly due to small cell sizes
for this pattern. Nonetheless, substantively it is important to discuss these differences because of
the persistent nature of depression for the women with this depression pattern.
Distribution of the post hoc findings indicate support for H1 in that mothers in the low
depression pattern had fewer risk factors than mothers in the other patterns. There is partial
support for H2 in that mothers in the high pattern had more risk factors than all the other
mothers. The story is complicated for mothers in the worsening pattern in that substantively they
have the second highest number of health and child health problems, but the values for food
insecurity and perceived economic strain are not different from mothers in the other patterns.
Qualitative analyses reported below reveal a different story than the statistics express for the
women in this pattern. There is also partial support for H3 in that health problems were higher
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risk factors for mothers in the high pattern and worsening patterns; however, food insecurity was
not as significant a risk factor for mothers in the worsening pattern as it was for mothers in the
high pattern. Again, qualitative analyses contradict the quantitative findings for the women in the
worsening pattern. As described earlier, decreases in main effect values after conducting the
MANCOVA suggest that the covariates may play a mediating role in the relationship between
the depression patterns and the dependent variables, lending support to H4 and H5. Qualitative
themes are organized below by risk and protective factors, and help illuminate the context for the
quantitative findings.

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Table 4.4. Risk And Protective Factors Distributed By Mothers’ Depression Patterns
Low
n = 63
M (SD)

Moderate
n = 24
M (SD)

High
n = 12
M (SD)

Improving
(H-L-L)
n = 45
M (SD)

Worsening
(L-H-H)
n = 32
M (SD)

4.7
(3.68)

10.4
(5.84)

a,f

4.7
(3.36)

5.6
(3.23)

a,b,f

Erratic
(H-L-H)
n = 24
M (SD)

Risk Factors
Number of health
problems**

3.5
(2.92)

Child health
problems**

2.4
(1.81)

2.9
(1.52)

5.5
(2.50)

3.0
(1.87)

3.7
(1.56)

2.9
(1.35)

Monthly income

1385
(980)

1230
(700)

958
(745)

1503
(859)

1062
(562)

1597
(884)

Food insecurity**

2.2
(3.04)

Protective Factors
Parental
Confidence**
Covariates
Parental support**

c,e

b,e

c

c,d,f

33.1
(4.37)

d,f

29.8
(5.49)

c

c

3.9
(3.86)
c

31.8
(4.70)
f

29.4
(5.38)

a,b,d,e,f

9.5
(3.78)

a,b,e

c

3.1
(3.79)
a

27.0
(3.90)

29.7
(4.52)

20.7
(9.30)

26.1
(7.93)

a

a

a

c

3.1
(3.60)
c

c

4.3
(2.76)
c

c

2.6
(2.60)
a

31.0
(4.41)

29.9
(4.02)

27.1
(7.93)

22.6
(6.90)

a,b

c
a,f
c
2.8
2.8
2.7
2.2
3.9
2.6
(1.43)
(1.43)
(1.5)
(1.23)
(1.44)
(1.40)
**p < .007. Note: Superscripted letters denote a post hoc significant difference between each
variable p < .05. a = stable low, b = stable moderate, c = stable high, d = improving, e =
worsening, f = erratic.

Economic strain**

The Story Behind the Numbers For Maternal Health
The post hoc analyses indicate that the women in the high depression pattern had more
health problems than the women in all the other patterns, although significance was achieved
only in comparison to the low and erratic patterns. Qualitative analyses reveal that the number
and complexity of health problems in the high depression pattern increased over the three waves
of the study. That is, the numbers of problems increased over time and are intertwined with
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mental health problems, such as depression and anxiety, consistent with what John, Kerby and
Hennessy (2003) call “multimorbidity.” In addition, as the health problems worsened, so did the
financial problems. These mothers had difficulty qualifying for social security disability, thereby
increasing the mothers’ sense of financial strain.
The case of Nan (age 42) is typical of the role of health problems for mothers in the high
depression pattern. She had a long history of health problems and surgeries since birth, but the
problems were made worse when she ruptured spinal disks as a result of a car accident, and then
had a fall that caused a re-injury. Surgery did not help and her doctor told her she would have to
live with the pain. However, the tremendous amount of pain from her back problems interfered
with other areas of her life, such as her ability to do fun things with her children: “I was real fun.
I would go to the park every day, I would chase them and run. I can’t do that now.” In addition,
frequent hospitalizations kept her from maintaining full time work. This caused a sense of
financial strain, and to make matters worse, her social security disability benefits were called into
question. It was thought that she had more mental health issues than physical because of the
abuse she endured while married to her ex-husband. Thus the relationship between her health
problems and depression was made complex by her past history and the processes by which her
health problems interfered with her ability to care for and support her family.
Contrary to the statistics reported in Table 4.4, the contextual story was similar for
women in the worsening depression pattern and for two of the women in the erratic pattern.
Their depression symptoms seemed to be made worse because their health problems interfered
with their ability to work and to parent in the manner they wanted. Trinity, a 39 year old single
mother with a worsening pattern, explains why she couldn’t hold a job, “Yeah I’m pretty limited
on what I can do…the doctor has me limited, I can only do this for so long or that for so long

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and…” In addition, her health problems interfered with her parenting, “I, I don’t think he [her
two year old son] understands it when I tell him it hurts when you sit on mommy’s lap. He don’t
understand, you know. Or mommy can’t carry you. Cause it hurts.”
The difference between these women and the mothers in the high depression pattern
appear to be that the women in the high depression pattern had a larger number of health
problems which weighed heavily on the quality of their lives. The contextual difference that
stood out was that mothers with high depression endured abuse at some point in their lives, either
as a child or by a former partner. It does not appear that the women in the worsening and erratic
patterns experienced abuse in their lives. Rather, other issues influenced their lives as much as,
or more than, their health issues. For example, though Steph (age 49) had many health issues,
her erratic depression pattern appeared to also be related to adjusting to and then losing custody
of her grandchildren: “Well the munchkins got taken away and, you know, my health seems to
want to be messin’ me up, and the winter is about ridiculous!”
In contrast to the above depression patterns, the women in the low, moderate, and
improving patterns spoke less about health problems affecting their lives. While health problems
were present, there were fewer reported and they just did not seem to be as much of a factor in
their depression symptoms or experience of life. For example, when Jillian (age 40), with a low
depression pattern, was asked about her back pain and arthritis, she responded, “Oh, I just take it
in stride.”
Child Health Problems can be a Factor
The mothers in the high depression category reported the highest average number of child
health problems. The children of these mothers seemed to be more likely to suffer from
problems related to the immune system, such as asthma, allergies, and frequent colds. They also

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were likely to have a mixture of emotional, behavior, and learning problems. Nan (age 42) was
very concerned about her son’s mental health because he had witnessed domestic violence closehand when she was married to her husband. She explains about her son’s anger problems:
“One time his father had me in a choke hold. [Her son] was two and I was
blacking out. His father always held him on every beating and I was beaten on a
daily basis…he held my son so I couldn’t hit him. So I would never fight back. So
anyway, my son grabbed him, he had a beard at the time, and screamed at him to
let mom go. Well he let me go and [her son] told my mom, his therapist and a
teacher that when he saved me that he wishes that I would have got a knife and
killed his father.”
The mothers in the worsening and erratic patterns reported fewer child health problems;
however, child behavior problems seemed to influence the quality of personal and family life.
Abiona (age 34), with an erratic depression pattern explained in wave two that the biggest
challenge facing her family was her sixteen year old daughter’s behavior, “She’s a problem
child… whatever problem we have, it’s normally, she’s like right there in the middle of the
storm.” Similarly, Mercy (age 27), with a worsening pattern said that her daughter’s behavior
problems made it difficult for her to work: “she has ADHD and ODD [oppositional defiant
disorder]…when she acts up I have to be there… she really acts up. Not just a little, and it lasts
for quite a while.”
Child health problems also were reported by the women in the low, moderate and
improving depression patterns. The types of child health problems reported were significant
problems, such as diabetes, heart murmurs, asthma, and seizure disorders, as well as mental or
behavioral problems such as anger management. Contextually, however, the relationship with

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mothers’ depression status is less clear. For example, Becca (age 23), with a moderately
depressed pattern, relayed that her daughter’s health problems made it difficult for her to work
because she was sick so often. In addition, she was frustrated with the health care system
because it took a lot of time and difficulty getting her daughter’s asthma diagnosed. Similarly,
Tomasa (age 32), also with a moderate pattern, experienced stress and anxiety when she could
not take her daughter to see a cardiologist for a heart murmur because her daughter’s Medicaid
coverage was not consistent. Tomasa was a migrant farm worker at that point, so Medicaid
coverage was dependent upon work availability. She explains:
“I applied this year in June but I want it for July because that’s the month that
there is less work for us…and I wanted Medicaid for my daughter ‘cause the
doctor said that she could hear a murmur and also she has been having chest
pains and trouble breathing…and still, I don’t have Medicaid for June for
her…and after July then they say that she won’t qualify for Medicaid no more.”
Thus for these women, stress was attributed more to difficulties with external systems that did
not adequately meet their children’s medical issues, and less to the child health problems per se.
Financial Strain and its Relationship with Food Insecurity and Other Stressors
The quantitative analyses show that monthly income was not significantly related to the
depression patterns, however, financial strain was. In fact, financial strain and food insecurity
were significantly associated with each other, and MANCOVA analyses suggest that financial
strain plays a mediating role. The qualitative analyses help explain the contexts in which this
relationship exists among the depression patterns. Indeed, the interrelationship among the risk
factors is complex.
Once again analyses show the mothers with high depression patterns as experiencing a

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higher level of risk. They were more likely to report a higher sense of financial strain, and the
mean food insecurity score was three times higher than for other patterns. Qualitatively, these
both seem to be related to the higher number of health problems experienced by mothers in this
group. Health problems interfered with the ability to work, and therefore income levels were
variable depending on whether the families qualified for welfare assistance or whether
participants qualified for social security disability benefits. This led to a sense of financial strain
because they had difficulties making money for food to last each month. According to Zola (age
45), welfare time limits were a concern because it was their only source of income and they had
not been able to qualify for social security disability (despite multiple health problems she and
her husband each suffered). They had trouble paying their mortgage, and because they could not
afford needed house repairs, such as leaky windows and doors, their utility bills were higher.
She further explains, “Yes, um, there was a time where we were having problems getting like the
food stamps or we’d have to go to the free pantry, and they really don’t give you enough for four
people. So we’d always let the kids eat first and him and I would either go without or whatever
was left over we would split it.” Feeding the children first was a common strategy mothers in the
high, worsening and erratic depression patterns used if there was a shortage of food. Jade (age
33) explains, “I go for a couple days without eating sometimes, or sometimes we have like a big
bowl of popcorn for dinner.”
Results of the post hoc analyses suggest that the mothers in the worsening and erratic
patterns were less likely to be food insecure than the mothers in the high depression pattern.
However, contextually the situation was very similar. For Trinity (age 39), a single mother with
a worsening pattern, health problems made it difficult for her to hold a full time job. She
received monthly cash assistance, however the amount varied dependent upon the child support

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paid by the fathers of her children. As the amount of child support varied, so did the amount of
welfare assistance. This variability and unpredictability caused a hardship for her. She explained
the process using one of the fathers, who had a steady job, as an example. The child support
came directly out of his paycheck to the county, and then the county would send a check to her.
It was supposed to be a certain amount, but the county did not send it on a regular basis or in
regular amounts: “…some weeks I might get a check for six dollars and some odd cents, and the
next week it might be the amount I’m supposed to get.” However, the cash assistance she
received from the state was based on income in the last 60 days, and there would be a two-month
lag in the amount of cash assistance. She further explains, “ OK my income is six hundred
dollars this month, but two months down the road they [her children’s fathers] might stop paying
their child support and my income’s going to drop two hundred, but they’re [the state] still going
back on this [month’s] income.” Thus she had difficulty budgeting money for food. When food
was low, she explained, “Well I just don’t eat. I mean, I make sure the kids eat and stuff but I
don’t always eat…it’s just stretching the food.” Trinity admitted that this happened multiple
times a week.
The women in the moderate depression pattern talked about feeling strained financially in
that money was tight and they worried about paying bills, but the strain seemed less daunting
than for the women in the high, worsening and erratic patterns experienced. For one woman in
this group, financial problems were tied to a lack of control on her part. She explains, “I’m not
very good with money. If I have money, I just spend it on what’s there.” The women in this
pattern also did not seem food insecure. Although they may have struggled with money for food
and time to cook, they indicated they could always stretch their groceries between pay days.
Financial strains were evident in wave one only for two of the women in the improving

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depression pattern. Their financial strain and food insecurity were tied to life circumstances that
were only present in the first wave of the study, and resolved by the second wave. In wave one
Kami’s (age 35) life circumstances were tied to an unhappy marriage in which her husband did
not contribute his earnings to support the family. According to Kami, she had to beg him for
money for food or bills, yet “He takes the food out of the kids’ mouth for his self. When I buy for
the kids he gets it.” When food would get low in her household she would “…fix my kids
something to eat and I won’t eat. As long as my kids have something in their stomach I won’t
eat.” By the second wave of the study, Kami had divorced her husband and was receiving help
from her parents. The story was different for Shakira (age 47), who survived mostly on welfare
benefits and help from family and friends. She struggled financially and with food insecurity all
three years of the study. Financial strain was related to the variability in social security
disability, food stamps, and other assistance, which did not coordinate well together, creating
food insecurity. She explains, “I cooked my last grits yesterday morning…I usually run out by
the end of the second week but see how many more stamps they done cut off?” She goes on to
explain that, “they[SSI] gave me a raise for January…give us a dollar raise and they took sixtyfive dollar food stamps for that dollar…and they went up on my rent, 60 dollars for that one
dollar.” However, even though Shakira struggled financially all three waves, her depression
improved after the first wave. Her resilience is likely explained by the level of social support she
received from family and friends, which will be described under social support.
Although the mothers in the low depression pattern experienced financial strain, they
talked more about the plans they had for improving their financial situation. Their talk was more
action oriented. For instance, Reba’s (age 34) husband obtained a job off of their family farm to
help bring in another income, which put a hardship on getting the farm work done. However,

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their children learned to pitch in, “…They’ve been used to doing that because…everybody has to
fill in, you know, everybody has to.” When their tractor was burned in a fire and needed to be
rebuilt, Reba describes how her family worked together, “My husband and I, we took it all apart,
our kids helped, you know, take bolts and stuff off of it…and it was kind of a family thing, and we
painted it...and then, there’s a lot of satisfaction when you get done.” For Reba, a pile-up of
financial issues all related to disasters that happened on their farm. However, the family kept
plugging away, tackling one issue at a time, and working together. The women in this pattern
also used coping strategies when food was low. Joelle (age 37) relayed that she used the local
food pantry, but only for nutritious foods. Reba “baked from scratch, canned food, and learned
how to make things like cheese.” Sometimes she would sell vegetables and homemade goods at
a local food market. Jillian’s (age 40) strategies were to use coupons, and buy things in bulk or
on sale.
Seeing Themselves as Confident in their Parenting
In terms of the mothers’ sense of parental confidence, the mothers in the low pattern had
a significantly higher sense of confidence than the mothers in the high, improving and erratic
patterns. Contextually, the mothers in all the patterns talked about similar parenting topics that
can be discussed in two broad themes concerning parental confidence: affective aspects and
instrumental aspects.
Affective aspects of parental confidence. Mothers in the low depression pattern were
likely to talk more about both themes than the other mothers; however, they were particularly
more likely to talk about the affective aspects. While these mothers discussed stressors in their
lives during their interviews, they also were equally likely to talk about their children in ways
that conveyed their pride in them, and they talked about fun things they liked to do with their

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children. For example, Joelle (age 37) really liked to just BE with her children. She had goals to
go to college when her son was old enough to go to Early Headstart. She used the time before
going to college to focus on being a mother to her children. She explains, “What do I do for fun?
My life is fun to me. I don’t go out. I don’t go to clubs…Things that I do that are fun for me are
things that I do with my kids. I take them to the park …personally, fun is doing things with
them.” She truly enjoyed being a mother, and this time with them was healing after leaving an
abusive relationship with her former partner. It boosted her sense of parental confidence.
Pride in their children is another sentiment expressed by the mothers in each depression
pattern. For example, Shakira (age 47), with an improving pattern, was proud of her children
because “none of them are on alcohol or drugs, or on the street….and [her adult daughter]
hasn’t had any kids.” Similarly, Trinity (age 39), with a worsening pattern, was proud of her
children and enjoyed watching them learn things, such as “watching [her adult son] learn the
value of money, and [her daughter] wanting to earn her own money.” Nan (age 42), with a high
depression pattern felt that the enjoyable part of parenting is “the rewards when they do
something the first time and you get to see it or their grades or just telling about their day. That’s
my high.”
Instrumental aspects of parental confidence. The mothers in the low depression
pattern also talked more about the instrumental aspects of raising children that gave them a sense
of parental confidence. For mothers in the low pattern, guiding their children and understanding
development as their children grew were two main facets of this theme. For example, Reba (age
34) home schooled her children, and as they were mature enough, she also guided them through
the process of raising, investing, and selling their own farm animals:
“The kids have cows in the herd....Every year we’ve started one out in 4-H…

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eventually when they get old enough, they can sell the cows, they’ll have some
money, they’ll have an investment…[her daughter] owns four head now…she sold
one bull calf this winter, that money went in her savings.”
Reba also felt a sense of parental confidence in the way she guided them through heart-breaking
times, such as the death of one of their animals. Reba felt the best part about being a parent was
“shaping young people.” Similarly, Jillian (age 40) enjoyed “teaching the kids to be self-reliant
and help around the house…and teaching the value of working, earning money, saving, and
tithing.” The mothers in the low depression pattern seemed to have the emotional and mental
resources to provide guidance as an instrumental aspect of parental confidence.
The mothers in the other depression patterns were more likely to discuss the instrumental
aspects of parenting confidence in terms of monitoring, disciplining, and daily parenting tasks.
This suggests a different orientation toward guidance than the mothers with low depression. It
seemed as though these mothers had less of an emotional reserve, such that their confidence
stemmed from ensuring their children were behaving well, doing what they were supposed to do,
and getting daily needs met. For example, when asked about her parenting strengths, Nan ( age
42), who had a high depression pattern, responded, “Screening their TV watching….and making
sure that they’re clean and fed and that they know how to read and do the best that they can.
That’s all I want from them. I don’t really ask for much and that’s all I expect from them.” For
Jade (age 33), also with a high depression pattern, discipline was important to parenting, “I like
to have fun with them, but I also want them to know that when it’s time for homework and it’s not
acceptable to be back-talking and stuff like that.” Shakira (age 47), with an improving pattern,
felt confident in her parenting because she “always tries to cook nutritious meals” for her
children. Because she was a nursing student, Louanne (age 22), with a moderately depressed

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pattern, expressed that she “likes to be educated on child development, safety, and stuff.” She
felt that this helped her to be a patient mother.
Social Support for the Parenting Role
Parental support has been defined in the Rural Families Speak study as social support that
the mother perceived she receives to support her in the parenting role. The post hoc analyses
once again reveal that mothers with a low depression pattern reported the highest perception of
parental support, while mothers with a high depression and erratic patterns reported the lowest
perceived support.
The mothers from the low depression pattern talked about a variety of sources of support,
both formal and informal. Formal sources for this sample tended to be social service agencies,
community agencies such as domestic violence centers, organizations that help out at Christmas
time, the farmer’s market, and physicians. Joelle (age 37) often turned to the domestic violence
shelter for support when she first moved to town, and when her car broke down she received help
paying for the repairs from several community agencies. Reba (age 34) liked to go to the local
farmer’s market because it provided space to sell produce, as well as an opportunity to meet new
friends. Jillian (age 40) felt supported by the specialist who worked with her daughter who had
attention deficit disorder. She appreciated his expertise, and especially the way he and she
worked together on her daughter’s progress.
Faith was an important aspect of parental support for the mothers with a low depression
pattern in two ways. The first was the support network from church members and Bible study
groups. Jillian described an incident when she was bedridden from an illness, “Shoot, when I
was off work, people from the church were bringing food all the time…they brung soups, and all
kinds of stuff.” The second way that faith was important was the support these mothers

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perceived directly from God. For example, each time Joelle told a story about someone helping
her, she thanked God, and called those efforts of help blessings. Reba exclaimed, after telling
about difficult times on the farm, “our faith has played a big part of that, relationship with
God…without that in our life, um, I really don’t know where we would be.”
There were several types of informal supports also available to the mothers in the low
depression pattern. Common sources were spouses/partners, parents, and other family members.
What seemed significant to the mothers in this pattern were the mutually supportive relationships
they built with neighbors and close friends. This type of support was talked about often during
their interviews. For example, when Joelle’s car was in repair, she would borrow her neighbor’s
car and barter gas money for running errands. She explains:
“[I] told him, ‘I know I ran your gas down, going back and forth, so do you want
me to give you $5, or do you want me to put it in the tank?’ He tells me, ‘You can
go ahead and put it in the tank.’ He needed milk, and I needed milk, so he says,
‘Why don’t you just take the car?’ So I took the car, and went and got milk for
[her son], bought milk for him, and put the gas in.”
Reba’s neighbors were particularly supportive when her husband had to drive a truck for a
living:
Our neighbor comes up probably two or three times during the week. It was
really nice, Monday night he invited us down to his house. We went down for a
pizza party…he comes up on weekends, usually Sunday morning, gets donuts for
us, over to Casey’s in Banker City. That’s been a weekly thing for the past year.”
According to the MANOVA results the mothers with a moderate depression pattern had a
mean score for parental support that was very similar to the mothers in the low depression

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pattern (29.4 vs. 29.8 respectively). Despite this result, two of the mothers in the moderate
pattern spoke very little about social support. For example, Louanne (age 22) felt closer to an
older couple she lived near than she did to her partner or her parents. During her second
interview she said she felt like “I’m doing it all myself.” Becca (age 23), on the other hand, said
her mother was important to her because she’s “always there for me,” and by the third wave she
felt her partner was more supportive than she had reported in earlier waves. However, there was
a stark contrast between these two mothers and the mothers with a low depression pattern.
Whereas the mothers with low depression pattern spoke of supportive relationships as part of
their daily lives, these two mothers spoke little about such relationships.
The exception to the story of parental support for the moderate pattern was Tomasa (age
32), a Mexican origin woman who was a migrant farm worker during wave one, but had settled
by the second wave. She was very close to her husband and daughter, as well as her parents and
relatives, and felt upset when she could not see them on a daily basis. The mutually supportive
relationships she had with her family were a big part of her daily life. For example, her parents
drove her daughter home after school every day, and Tomasa stopped by her parents’ house
twice a day to give her mother insulin injections.
Quantitatively, the mean score for parental support for the improving and worsening
depression patterns were similar and not statistically significantly different (26.1 and 27.1
respectively). However, the stories of support were qualitatively different. For two of the
women with an improving pattern, the sources and numbers of support varied, however, the
common theme among these women was that there was a significant life stressor or crisis in
which support systems encompassed the mothers in a supportive safety net. Once the stressor
was resolved, their support systems stabilized. The case of Gabby, a 38 year old single mother

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of three boys, exemplifies the analysis. During wave one she relied on several neighbors to
provide child care so she could hold a job. They had a mutually supportive system in that she
often baked for neighbors in exchange for child care for her sons. However, when her oldest son
fell into legal trouble, stress was high and her support system rallied:
Because of my oldest one. I lost it last week. I mean, if it wouldn’t have been for
Diane and a couple of the neighbors around here, I don’t know what I would have
done…. I’m laying in friends, lots of friends over here …Oh there’re still here,
trust me! I had to write down my work schedule from day to day…if I don’t show
up at their house at least once during the day, night, whatever, they’re down here
wanting to know what I was doing.
Analysis of Shakira’s (age 47) interviews, on the other hand, provides a different
perspective about the role of social support. Across all three interviews Shakira’s stressors
remained the same. She had many health problems and financial stressors, and her interviews
revealed that she was food insecure each year. The difference for her was that for wave one, she
lived at her mother’s home to take care of her during an illness, so Shakira was not near her vast
support network. She was isolated during the first wave and her depression scores were high.
Her depression scores were lower the second and third year, despite a multitude of stressors
(including a house fire). The only difference was that she had steady access to multiple sources
of formal and informal supports throughout her community, such as extended family, friends,
church members, neighbors, school teachers and counselors, and the Red Cross. Shakira had a
knack for garnering support, and her second and third interviews were full of lengthy examples.
For the women in the worsening pattern, the support they received seemed steady
throughout the study and similar to the support that mothers in other depression patterns

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discussed. For example, Trinity (age 39) describes her relationship with a close friend:
“Annette, my neighbor down the street…is always, always, been there through the
good, through the bad. You know…we can confide in each other and everything
and she’s the one I go to if I need that roll of toilet paper or cough drops or
something. And, and I do things for her, she does things for me, you know…And
it’s a friendship you don’t find very often anymore.”
However, despite the support they received, the depression scores worsened over the course of
the study for the mothers in this pattern as their life stressors worsened (e.g., health problems,
financial strain, food insecurity).
The mothers in the high depression pattern had the lowest mean score for parental
support of all the depression patterns (20.7), yet contextually, they talked about the support they
received from their networks more than the mothers in the erratic pattern (26.1). Nan (age 42),
for example, relies on neighbors to keep an eye on her and her children, such that she felt they
were a second family. The mothers in the erratic pattern had only a few family members or close
friends on which they could rely for support. For example, Abiona, a 34 year old married
African American mother, explains that, “[Her husband] is always there and I haven’t had no
one else.” Sancha, a single mother of Mexican origin, talked about the support she received
from her parents “they help me [with taking care of her daughter], but for moral support and
stuff like that, they’re not really…there.”
Discussion
The present study employed a mixed methods design to link a risk and resilience lens
with components of Bronfenbrenner’s Process-Person-Context-Time (PPCT) model (1986, 1989,
1994, and as discussed by Tudge, Mokrova, Hatfield & Karnik, 2009). While much of the

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developmental and resilience literature has focused on the child, this research is unique in its use
of ecological and resilience frameworks to investigate resilience processes of the mothers as the
developing individual of interest. MANOVA and MANCOVA procedures provided insight into
how the risk and protective factors organize themselves amid depression patterns of this sample
of rural low income women. Qualitative analyses provided insight into the context of the lives of
the mothers in the sample and provided a partial explanation for the organization and
interrelationships of the risk and protective factors.
One of the most important contributions of this study is the way quantitative and
qualitative analyses together highlighted the complex proximal processes involved in the
interplay between characteristics of the mothers (depression pattern, health problems, and
perceptions of parental confidence), and characteristics of the context (child health problems,
financial strain, family food insecurity, social support). These findings were most compelling
when considering the cumulative and interactive effect of risk factors for mothers in higher risk
depression patterns. From a resilience stand point, this study shed light on the various ways that
protective factors, such as sense of parental confidence and social support, were important to
mothers in each depression pattern.
Multiple Risks are Related to Multiple Morbidity
There is a complex relationship between depression and health, financial strain and food
insecurity, and this was especially the case for the mothers with high, worsening and erratic
depression patterns. Consistent with the multimorbidity concept (John, Kerby, & Hennessy,
2003) the mothers in these patterns experienced multiple physical health problems, as well
depression over the course of the three waves of the study, and for many of the women, health
and depression problems increased together over time. This is consistent with Moussavi,

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Chatterji, Verdes, and Tandon, and colleagues (2007), who found that the presence of depression
is associated with worsened health outcomes. This study provided insight into how that can
happen when considering the daily lives and struggles of the mothers in this sample. For
example, the findings shed light on the importance of financial strain and food insecurity to the
complex relationship between health and depression, and supports earlier findings from Rural
Family Speak studies (Dolan, Richards, Sano, Bauer, & Braun, 2005; Olson, Anderson, Kiss,
Lawrence, & Seiling, 2004). That is, because the mothers have multiple health problems and
experience depression, they are unable to maintain steady employment to provide an income
with which to feed their families consistently. This contributes to an ongoing sense of financial
strain. For these women, qualification for social security disability benefits is elusive and the
time clock associated with welfare reform is an intimidating presence.
Depression and the Role of Parental Confidence
Qualitative analyses revealed two dimensions of parental confidence that seemed to have
relevance for the depression patterns, an affective dimension and an instrumental dimension. For
instance, mothers in the low and improving patterns talked about both dimensions of parental
confidence in their interviews, with a majority of stories related to affective aspects of loving
their children, spending time with them and guiding them. However mothers in the high,
worsening and erratic patterns spoke more about the instrumental dimension of parental
confidence, particularly disciplining and monitoring activities that would ensure their safety and
acceptable behavior. From a resilience perspective this makes sense. The pile-up of stressors
these women experienced (multiple risks and multimorbidity), is likely to influence their
perceptions about their capabilities and resources. In the resilience literature, subjective
appraisals of capabilities are important for balancing life demands (Masten & Powell, 2003;

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Patterson, 2002a, 2002b). For women in the higher risk patterns, their sense of parenting
capabilities may be tied to teaching their children good manners and behavior, and how to
survive stressful living conditions.
Depression and its Complex Relationship with Social Support
Classic research on the stress process (Pearlin, Menaghan, Lieberman, & Mullan, 1981)
suggests that social supports act to buffer depression indirectly by reinforcing self-concepts and
are beneficial to those who need support most. However, findings from this study suggest that
social support is beneficial in various ways for those who perceive that they receive it and know
how to actively tap into it. This was clearly observed in the women with low and improving
depression patterns. The social support these women received seemed to reinforce their
confidence. Further, under stressful circumstances, there was mutual interaction between the
women and their support systems, such that the women directly tapped into support systems, and
their systems rallied for them.
Interestingly, the relationship the women in the moderate pattern have with social support
is more consistent with negative attachment cognitions of depressed individuals (Bell, 2009;
Hammen, 2006) in that they did not perceive that they received social support, nor did they
report actively pursuing or tapping into such resources. When comparing women in the low and
improving patterns with women in the moderate depression pattern, Bronfenbrenner’s ProcessPerson-Context-Time model (PPCT) (as discussed by Tudge, Mokrova, Hatfield & Karnik,
2009), may help explain the differences. Specifically related to the Person in the model, he
proposed that individuals possess characteristics which determine how interactive an individual
will be with environments, and include temperament, motivation and persistence. Motivation is
an important characteristic into which an individual can tap to influence her own development

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and change the environment. Similarly, but from a resilience perspective, Masten and Powell
(2003) list several characteristics, or attributes, the developing individual possesses that help to
outweigh risks and counterbalance adversities. Findings from this study suggest that women in
low and improving patterns possess the motivation and resilience characteristics to tap into and
receive social support, whereas the women in the moderate pattern may not possess those
characteristics.
The findings for women in the high and worsening patterns indicate that they perceive
and tap into social support systems; however, their risk circumstances (high depression scores,
multiple health problems, children with health problems, financial strain and food insecurity)
outweigh the beneficial effects of social support. Additionally, the connection between a history
of abuse and depression cannot be ignored for women in the high depression group. According
to theories of interpersonal vulnerability to depression (Hammen, 2006; Herzberg, Hammen,
Burge, Daley, Davila & Lindberg, 1999), early attachment experiences and dysfunctional
relationships have been shown to be associated with depressed persons’ perceptions of social
support. It is possible that the abuse they endured earlier in life contributed to a sense of
helplessness, such that a feeling that “nothing will help” can limit the effectiveness of any
protective factors, such as parenting confidence or social support.

Limitations
Categorizing the sample into depression patterns and using a mixed methods design
provided a unique contribution to the literature on maternal depression, as well as the literature
on risk and resilience. However there are limitations to the study. First, the number of
depression patterns employed, combined with a limited sample size provided for small cell sizes,

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particularly for the high depression pattern. Small cell sizes limited statistical analyses that
might have considered interactive effects. Future studies should consider a categorization
scheme that would reduce the number of depression patterns, or employ a larger sample to
ensure power to conduct more sophisticated analyses.
Second, while the CESD (Radloff, 1977) is commonly used to measure depression in the
general public, it may be useful to use an instrument designed for clinical samples, such as the
Beck Depression Inventory. Some of the characteristics of women in the moderate depression
pattern were consistent with interpersonal and cognitive theories of depression, particularly the
perceived lack of social support. It may be that the nature of the CESD does not detect persistent
depression that may be more consistent with interpersonal and cognitive vulnerabilities.
Last, purposive sampling including three extreme cases for the qualitative analyses
enabled rich exploration and shed light on the relationship between depression patterns and
common risk and protective factors; however the small sample within each pattern may have
limited theoretical saturation. Future studies could expand such investigations to include larger
samples within each pattern. Conversely, future studies also could focus sampling frames to
explore contextual nuances of depression patterns that may be identified among other
populations, such as fathers, urban populations, ethnic and minority populations, and specific age
groups. Despite the stated limitations, the compelling findings using mixed methods and a
longitudinal depression categorization have implications for further studies with larger samples.
Implications for Policy, Practice and Research
The complex relationship between depression, maternal health problems, child health
problems, financial strain, and food insecurity indicates a need for better coordination of policies,
services, and programming for depressed mothers and their families. Better policies are needed

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for determining disability benefits when multiple risk and multimorbidity is present. The U.S.
Department of Health and Human Services has stated that major depression is the leading cause
of disability in the United States (1999), yet there were depressed mothers in this sample with
multiple health problems who could not qualify for disability benefits. Policies that simplify
forms and processes may help physicians assist and advocate for their patients.
Better communication systems between medical and social service agencies also need to
be developed to help identify gaps in services and connect patients/clients with more effective
formal and informal support systems. That depression and health problems, especially health
problems that are manifested in chronic pain, are highly interrelated points to a need to educate
physicians and other health and social service professionals on the importance of consistent
screening for depression among patients with multiple health problems, and to screen parents of
children who have multiple health problems. Previous findings from the Rural Families Speak
project indicate that rural low-income mothers are less likely to self-report depression (Simmons
& Huddleston-Casas, 2007), which suggests that many of these women do not get education on
access to services that may help them and their families.
For the mothers in this study, a sense of parental confidence and perceived social support
were important protective factors. Therefore, it is important that parent and family life education
programs assist mothers who experience depression with identifying and tapping into parenting
strengths and support networks. The findings also have implications for a collaborative role for
educators to work with community agencies and policymakers to improve accessibility and
outreach to better engage depressed mothers and their families.
An action-oriented focus of “tapping into” internal strengths and external supports points
to the interactive nature of development (Bronfenbrenner, as discussed by Tudge, Mokrova,

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Hatfield & Karnik, 2009) and resilience processes (Masten & Powell, 2003) and emphasizes an
empowered, active role in mothers’ own parental growth. The findings have implications for
research to further explore possible dimensions to parental confidence and social support and
their relationship to resilience processes, both at individual and family levels.

Conclusions
A strength of this study was the use of a mixed methods and longitudinal design to gain a
better understanding of the ways risk and protective factors organize themselves among
longitudinal depression patterns. The findings contributed to a better understanding of the
complex relationship among and between risk and protective factors for mothers with
depression, and particularly highlighted the interrelationship between depression and health
problems. Also highlighted in the findings was the interactive nature of personal characteristics
for garnering and tapping into internal and external sources of strength to off-set or cope with
stressful life circumstances.

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CHAPTER 5
DISCUSSION OF THE TWO STUDIES
Introduction
This dissertation had two specific purposes: to explore the context and distribution of risk
and resilience factors among six depression patterns identified in a sample of rural low-income
mothers over three waves of data; and to connect individual resilience and family resilience
approaches. The six depression patterns identified included:


“Stable low” pattern, which consisted of mothers who reported depressive symptoms
consistent with categories one and two (nondepressed and mildly depressed), and who
remained in those low categories across time (low  low  low).



“Stable moderate” pattern consisted of mothers who reported depressive symptoms in the
moderately depressed range over time (mod  mod  mod).



“High depression” pattern consisted of mothers whose depression remained in the
severely depressed category across all three waves (high  high  high).



“Worsening depression” consisted of mothers experiencing few depressive symptoms
during the first wave, but more severe depressive symptoms over the next two waves
(low  high  high).



“Improving depression” consisted of mothers who experienced high depression the first
wave, but reported fewer symptoms by the third wave (high  low  low).



“Erratic depression” was an irregular pattern where symptom levels changed dramatically
each year of data collection (e.g. very high  very low  very high).

Common risk and protective factors for maternal depression have been identified in the
literature on depression (e.g., Brown, Brody & Stoneman, 2000; Casey, Goolsby, Berkowitz,

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Frank et.al., 2004; Coiro, 2001; Dennis, Parke, Coltrane, Blacher, & Borthwick-Duffy, 2003;
Ennis, Hobfall & Schroder, 2000; Jackson, 1998, 1999; Jackson & Huang, 1998; Ross, 2000;
Siefert, Heflin, Corcoran, & Williams, D. 2004; Taylor, Rodriguez, Seaton, & Dominguez, 2004)
and among several studies stemming from the multi-state Rural Families Speak Project (e.g.,
Bulock, 2004, 2007; Dolan, Richards, Sano, Bauer, & Braun, 2005; Garrison, Marks, Lawrence
& Braun, 2004; Islam, 2004; Kim, Seiling, Stafford & Richards, 2005; Olson, Anderson, Kiss,
Lawrence, & Seiling, 2004). Similar risk and protective factors were identified in the present
studies of rural low-income mothers. However, the mixed methods, contextual nature of these
studies revealed a diverse way with which resilience processes unfolded among rural low-income
families in which mothers experienced differing patterns of depression.
Study 1 used a grounded theory approach and revealed Sources of Strength (positive
perspective, parenting strengths, perceived family strengths, resourceful partner/spouse, social
support, permanent employment, and investing in self) and Sources of Stress (financial strains,
negative life events, negative outlook, stressful relationships, low perceived access to social
support, pile-up of health problems, “getting the run-around,” and history of abuse) as higher
level categories that pulled the data together during the axial coding process (LaRossa, 2005).
Although these higher level categories reflected common themes across the depression patterns,
the individual and family processes involved revealed that the Picture of Resilience for each
depression pattern differed.
In Study 2 MANOVA and MANCOVA procedures were used to determine the
distribution of common risk and protective factors across the depression patterns. As expected,
mothers with low or improving depression patterns revealed more protective factors and fewer
risk factors, while mothers in high, worsening and erratic patterns revealed fewer protective

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factors and more risk factors. MANCOVA results suggest that social support and economic
strain play mediating roles in the relationship between the depression patterns and the other
factors. More interesting findings surfaced when contextual analyses revealed the complex
interactions among risk factors for women in the high, worsening and erratic patterns.
The two mixed methods studies used the same quantitative and qualitative datasets, and
the same subsample for qualitative analyses, and presented findings that were both similar to one
another and distinct. One of the most important contributions of this dissertation is the way the
combination of quantitative and qualitative analyses highlighted the complex proximal processes
involved in the interplay between characteristics of the mothers (depression pattern, health
problems, and perceptions of parental confidence) and characteristics of the context (child health
problems, financial strain, family food insecurity, social support, perceptions of family strengths
and resourceful spouses) (Bronfenbrenner as discussed by Tudge, Mokrova, Hatfield & Karnik,
2009). These findings were most compelling when considering the cumulative and interactive
effect of risk factors for mothers in higher risk depression patterns. From a resilience stand point,
this dissertation also shed light on the various ways that protective factors, such as sense of
parental confidence and social support, were important to mothers in each depression pattern.
This chapter will review and integrate the findings, discuss theoretical connections between
resilience at the individual and family levels, and then discuss limitations, implications for
research, practice and policy, lessons learned, and conclusions.
Multiple Risks are Related to Multiple Morbidity
Study 1 found that, for the women in the three maladaptive patterns, high, worsening, and
erratic depression, each source of stress (pile-up of health problems, financial strains, stressful
relationships, and “getting the run-around”) appeared to exacerbate the others. It was as if these

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women were caught up in a swirling vortex of unbearable stressors. The findings for Study 2
were similar and found that the complex relationship between depression and health and
financial strain also involved food insecurity for the families. Consistent with the multimorbidity
concept (John, Kerby & Hennessy, 2003) the mothers in these patterns experienced multiple
health problems, as well depression over the course of the three waves of the study, and for many
of the women, health and depression problems increased together over time. This is consistent
with Moussavi, Chatterji, Verdes, and Tandon, and colleagues (2007), who found that the
presence of depression is associated with worsened health outcomes. The two studies provided
insight into how that can happen when considering the daily lives and struggles of the mothers in
this sample. For example, the findings shed light on the importance of financial strain and food
insecurity to the complex relationship between health and depression, and supports earlier
findings from Rural Families Speak studies (Dolan, Richards, Sano, Bauer, & Braun, 2005;
Olson, Anderson, Kiss, Lawrence, & Seiling, 2004). That is, because when mothers have
multiple health problems and experience depression, they are unable to maintain steady
employment to provide an income with which to feed their families consistently. This contributes
to an ongoing sense of financial strain. For these women, qualification for social security
disability benefits is elusive, and the time clock associated with welfare reform is an intimidating
presence. Experiences with health and social service agencies compounded the stress for these
women and led to a sense that they were “getting the run-around.”
The metaphor of a “swirling vortex” highlights the additive, interactive, and possibly
reciprocal process nature of risk and resilience, compared with past studies that employed a pileup-of-stressors metaphor (McCubbin & Patterson, 1983; Wickrama, Surjadi, Lorenz, Conger &

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Walker O’Neal, 2012). This metaphor also provides a visual reminder of how difficult it can be
for families facing significant adversity to move forward.
Intentional Activation of Sources of Strength
The two most important sources of strength common to both studies were parental
confidence and social support. This was true for all the women across the depression patterns.
However, the manner in which these sources of strength were activated differed by depression
pattern. For example, Study 1 revealed that the women in the two bonadaptive patterns, stable
low and improving depression, and their families faced serious adversities in their lives.
However, the sources of strength evident in these women and their families (parental
confidence/strengths, perceived family strengths, resourceful spouse, investing in self, and social
support) could be characterized as tools that were activated intentionally by the women (and their
spouses or partners) to keep their families working together and moving in a forward direction.
Study 2 revealed two dimensions of parental confidence that seemed to have relevance
for the depression patterns, an affective dimension and an instrumental dimension. For instance,
mothers in the low and improving patterns talked about both dimensions of parental confidence,
with a majority of stories related to affective aspects of loving their children, spending time with
them and guiding them. However mothers in the high, worsening and erratic patterns spoke
more about the instrumental dimension of parental confidence, particularly disciplining and
monitoring activities that would ensure their safety and acceptable behavior. From a resilience
perspective this makes sense. The pile-up of stressors the women in the high, worsening and
erratic patterns experienced (multiple risks and multimorbidity) is likely to influence their
perceptions about their capabilities and resources. In the resilience literature, subjective
appraisals of capabilities are important for balancing life demands (Masten & Powell, 2003;

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Patterson, 2002a, 2002b). For women in the higher risk patterns, their sense of parenting
capabilities may be tied to teaching their children good manners and behavior and how to survive
stressful living conditions.
Classic research on the stress process (Pearlin, Menaghan, Lieberman, &Mullan, 1981)
suggests that social supports act to buffer depression indirectly by reinforcing self-concepts, and
are beneficial to those who need support most. However, findings from both studies, but
especially Study 2, suggest that social support is beneficial in various ways for those who
perceive that they receive it and know how to actively tap into it. This was clearly seen in the
women with low and improving depression patterns. The social support these women received
seemed to reinforce their confidence. Further, under stressful circumstances, there was mutual
interaction between the women and their support systems, such that the women directly tapped
into support systems, and their systems rallied for them (Thoits, 2011).
The findings for women in the high and worsening patterns indicate that they perceive
and tap into social support systems as well; however, their risk circumstances (high depression
scores, multiple health problems, children with health problems, financial strain, food insecurity,
and “getting the run-around” from formal sources of support) outweigh the beneficial effects of
informal social support. Additionally, the connection between a history of abuse and depression
cannot be ignored for women in the high depression group. According to theories of
interpersonal vulnerability to depression (Hammen, 2006; Herzberg, Hammen, Burge, Daley,
Davila & Lindberg, 1999), early attachment experiences and dysfunctional relationships have
been shown to be associated with depressed persons’ perceptions of social support. It is possible
that the abuse they endured earlier in life contributed to a sense of helplessness, such that a

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feeling that “nothing will help” can limit the effectiveness of any protective factors, such as
parenting confidence or social support.
The Puzzle of the Women in the Moderately Depressed Pattern
Study 1 revealed that two of the women in the moderate depression pattern were
qualitatively unique in their resilience processes in that they reported the fewest and least adverse
sources of stress as well as the fewest sources of strength. The negative outlook on life they
possessed may be more consistent with theories of cognitive and interpersonal vulnerabilities to
depression. Negative cognitions may lead them to ruminate about negative events or stressors in
their lives (Abramson & Alloy, 2006; Gotlib & Joorman, 2010; Joorman, 2009), which may
prevent them from identifying possible solutions and moving forward. Their perceptions of
having low levels of support available to them, and “doing it all alone” may be consistent with
dysfunctional interpersonal schemas (Hammen, 2006; Hammen, Burge, Daley, Davila, Paley &
Rudolph, 1995), and may explain why these women did not actively engage support networks to
help off-set their stressors.
The findings from Study 2 were similar for these women, and further suggested that the
relationship the women in the moderate depression pattern have with social support is consistent
with negative attachment cognitions of depressed individuals (Bell, 2009; Hammen, 2006) in that
they did not perceive that they received social support, nor did they report actively pursuing or
tapping into such resources. When comparing women in the low and improving patterns with
women in the moderate depression pattern, Bronfenbrenner’s Process-Person-Context-Time
model (PPCT) (as discussed by Tudge, Mokrova, Hatfield & Karnik, 2009), may help explain
the differences. Specifically related to the Person in the model, he proposed that individuals
possess characteristics which determine how interactive an individual will be with environments,

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and include temperament, motivation and persistence. Motivation is an important characteristic
into which an individual can tap to influence her own development and change the environment.
Similarly, but from a resilience perspective, Masten and Powell (2003) list several
characteristics, or attributes, the developing individual possesses that help to outweigh risks and
counterbalance adversities. Findings from this study suggest that women in low and improving
patterns possess the motivation and resilience characteristics to tap into and receive social
support, whereas the women in the moderate pattern exhibit characteristics consistent with
cognitive and interpersonal vulnerabilities to depression, including negative attachment
cognitions.
That their depression scores stayed in the moderate range over the course of the study is
puzzling, but it is possible that they had not encountered a negative life event traumatic enough
to trigger higher levels of depression (Levinson, 2009). It is also possible that the instrument
used to measure depression in community-based samples (the CES-D, Radloff, 1977) did not
capture enough depressive symptoms to adequately characterize depression in these women.
Last, there may be a developmental aspect not considered in the analyses. These two women
were the youngest in the qualitative sample. Further research with larger samples should include
age as a developmental variable to be explored in relation to moderate depression and
vulnerabilities to depression, and perhaps in relationship to early motherhood.
A Cultural Role in Resilience Processes
Findings from Study 1 indicate that there was a cultural factor that seemed to play a role
for the two women in the study who were of Mexican origin. Family togetherness (familismo) is
an important cultural value for Latino families and has been shown to play a role in their sense of
resilience (Parra-Cardona, Bulock, Imig, Villarruel & Gold, 2006). However, family

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togetherness was a major source of stress for both of these women, and for two very different
reasons. Nostalgia for migrant life when she worked with her family on a daily basis contributed
to Tomasa’s sense of having mixed feelings about life satisfaction, despite her educational
attainments and her family’s improving financial situation. Sancha, on the other hand, felt
constrained by her family and the level of control they exerted over her and her daughter. She
seemed to feel conflicted by a desire to pull away from her family and feel independent, and a
sense of duty and obedience to the cultural value. The disparate stories of these two women
around a central cultural value highlights the complexity of influences cultural values can have
on families, and how important they are to the resilience process (Parra-Cardona, Bulock, Imig,
Villarruel & Gold, 2006). This is consistent with Ungar’s (2010) recommendation that culture
and context play a central role in research and practice when working with ethnic and minority
populations. For instance, concepts and variables such as life satisfaction and social support may
need to be conceptualized differently to include key cultural values (Raffaelli, Tran, Wiley,
Galarza-Heras & Lazarevic, 2012) when conducting research with ethnic and minority
populations. Perhaps more importantly, the complexity discovered in these analyses suggests a
dimensional aspect to this important cultural value that should be investigated further.

Theoretical Implications
This dissertation offers a unique contribution that begins to theoretically connect
resilience at the individual and family levels. Chapter two introduced an ecological and
resilience concept matrix, using Bronfenbrenner’s Process-Person-Context-Time model as a
structural framework. Specifically, the concept matrix ties resilience at the individual level with
Bronfenbrenner’s ecological model, and resilience at the family level with the Bubolz and

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Sontag family ecological model. The concept matrix (Table 5.1) has been revised to incorporate
findings from the two studies to illustrate connections.

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Table 5.1. Ecological and Resilience Concept Matrix with Study Results
Bronfenbrenner’s Concepts from Individual Bubolz & Sontag’s
Concepts from Family
Ecological
Resilience
Family Ecological
Resilience
Framework
Framework
Proximal processes: Risk factors and
Resource management and decision making of
Protective mechanisms with which a mother
the rural low-income family: Adjustment,
interacts within the proximal environment
adaptation of a family in response to adversity


Multiple risks related to multiple morbidity (“swirling vortex of
unbearable stressors”)
 Intentional activation of sources of strength
 Cultural roles in resilience processes
Person: Characteristics/ attributes of the
Family: Capabilities, resources, meanings and
mothers and their propensity for adaptation to
beliefs of rural low-income families to respond
adversity
and adapt to change and adversity








Pile-up of health problems
Negative outlook
Positive perspective
Investing in self
Parenting strengths/confidence
Ability to tap into social support
Puzzle of the moderately depressed
mothers






Child health problems
Resourceful spouse/partner
Family strengths
Parental confidence

Context: Risk factors and protective factors
within the mothers’ environment or situation

Environments: Significant risk exposure and
protective factors within proximal and distal
environments which can affect a low-income
rural family’s functioning















Social support
Financial strain
Food insecurity
Negative life events
Getting the run-around
History of abuse
Stressful relationships

Rural low-income mothers’ developmental
outcomes over time


Social support
Financial strain
Food insecurity
Negative life events

Rural low-income family level outcomes over
time

Rural low-income mothers’ depression patterns

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Table 5.1 illustrates that ecological and resilience frameworks share common
perspectives on the development of individuals and families. Specifically, they both focus on the
abilities and processes of individuals and families as they adapt and change in response to
stressors that occur within families and external environments. Resilience theory at the
individual and family levels further share common criteria for evidence of resilience. The first
criterion is that an individual or family has experienced significant adversity. Second, that the
individual or family exhibits competent functioning after experiencing adversity. Last, that
resilience is not static or linear. Rather, resilience is a developmental process that occurs over
time, and is iterative in nature (see several chapters of Becvar, 2013).
The metaphor of the “swirling vortex of unbearable stressors” (in the top row of Table
5.1), is a poignant illustration of Bronfenbrenner’s notion that “progressively more complex
reciprocal interaction” takes place as individuals develop within a family context (Tudge,
Mokrova, Hatfield & Karnik, 2009, p. 200). This metaphor also illustrates the relationship
between risk and resilience processes at the individual and family levels. For example, mothers
in the high, worsening and erratic depression patterns were more likely to suffer from multiple
health problems, which limited employment options, which was related to financial strain.
MANOVA analyses showed that these stressors were related to family level stressors, such as
child health problems and food insecurity. Thus, the mothers’ risks were related to and likely
influenced the risks of the families. However, the qualitative analyses helped to shed light on
potential resilience processes taking place among these mothers and within their families in the
shared context. Despite their dire circumstances, many of these mothers tried to maintain
positive perspectives about their lives, their families, and about themselves as parents. Their
strategy to feed the children first when facing food insecurity implies decision making and

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resource management capacities, which suggests attempts at adjustment or adaptation at the
individual level to promote resilience at the family level.
The other proximal processes identified by the two studies, “intentional activation of
sources of strength” and “cultural roles in resilience processes,” are further examples of the
interactions between characteristics of the mothers, the characteristics of their families and the
shared family contexts. “Intentional activation of sources of strength” highlights the notion that
resilience is not passive. Rather, it is an active and interactive process. “Cultural roles in
resilience processes” supports the limitations that have been recognized in the literature. Current
knowledge about resilience relies on White, middle class, majority population assumptions
(McCubbin & McCubbin, 2013). The findings related to culture in these current studies reveals
that resilience research and theories have not yet discovered the depths of resilience processes of
ethnic and minority populations.
The ecological and resilience concept matrix is a model that can be used for further
research and theory development. In particular, resource management, decision making, and
problem solving are potential avenues of research to explore further the connections between
individual resilience and family resilience, particularly when a parent is the developing
individual of interest. It makes intuitive sense that parents have the integrity and competent
functioning of the family as a goal during times of adversity. The findings from these studies
point to the importance of exploring the resilience of parents as individuals who strive for
resilience within their families. How parents navigate effective decision making and problem
solving for the family is a key link between resilience at the two levels.
Family resilience theorists emphasize that research and family resilience theory
development should include the collection of family level data (DeHaan, Hawley & Deal, 2013),

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and the use of longitudinal, process oriented quantitative methods, such as configural frequency
analysis (von Eye, as discussed in DeHaan, Hawley & Deal, 2013). The results from these two
studies suggest that mixed methods approaches are promising when sample sizes are limited,
especially when the sample is divided among categories of nominal level variables. The
inclusion of qualitative data can highlight family processes that may not be captured from
quantitative data, especially such family processes as decision making and problem solving,
which can influence resilience at the individual and family levels.

Limitations
Categorizing the sample into depression patterns and using a mixed methods design
provided a unique contribution to the literature on maternal depression, as well as the literature
on risk and resilience. Also, this dissertation offers a unique contribution by providing insight
into the contextual nuances that distinguished depression patterns among the rural low-income
mothers in this study, as well as resilience processes the mothers and their families developed;
however it is not without limitations.
First, the family resilience literature suggests that shared meanings of challenges and
capabilities among family members are central to the concept of family resilience. Although
spouses/partners and children were sometimes present during the interviews, there were only two
cases (in this specific sample) in which a spouse or partner contributed information to the
interviews. Information obtained from other household members may have provided a better
means for observing the processes by which the families created shared meanings and situational
appraisals. Their participation may have provided better insight into the effect of the mothers’
depression on the family system.

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Second, data on depression for this study were obtained from a community-based sample
using a self-report instrument (the CES-D, Radloff, 1977) commonly used to measure depression
in the general public. While two of the mothers reported that they were taking medication for
depression, little is known about the nature of the diagnosis and the lifetime history of depression
among the women in the sample. For instance, among the women who did report that they were
taking medication, there is no information on who made the diagnosis (primary physician or
psychiatrist), how they made the diagnosis (e.g., structured clinical interview versus self-report),
or the history and course of their depression (e.g., age at first onset, whether they were currently
in a major depressive episode or in recovery, or average length of depressive episodes).
Therefore, the findings of this study may not generalize to populations of clinically diagnosed
depression. Also, it may be more useful to use an instrument designed for clinical samples, such
as the Beck Inventory (Beck, Steer & Garbin, 1988). Some of the characteristics of women in the
moderate depression pattern were consistent with interpersonal and cognitive theories of
depression, particularly the perceived lack of social support (e.g. Hammen, 2006; and Herzberg,
Hammen, Burge, Daley, Davila & Lindberg, 1999). It may be that the nature of the CESD does
not detect persistent depression among participants with possible depression vulnerabilities.
Third, the number of depression patterns employed, combined with a limited sample size
provided for small cell sizes, particularly for the high depression pattern. Small cell sizes limited
statistical analyses that might have considered interactive effects. Future studies should consider
a categorization scheme that would either reduce the number of depression patterns, or recruit a
larger sample to ensure power to conduct more sophisticated analyses.
Last, purposive sampling including three extreme cases for the qualitative analyses
enabled rich exploration and shed light on characterization of the depression patterns, however

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the small sample within each pattern may have limited theoretical saturation. Future studies
could expand such investigations to include larger samples within each pattern. Conversely,
future studies also could focus sampling frames to explore contextual nuances of depression
patterns that may be identified among other populations, such as fathers, urban populations,
ethnic and minority populations, and specific age groups. Despite the stated limitations, the
compelling findings using mixed methods and a longitudinal depression categorization have
implications for further studies with larger samples.

Implications for Research, Policy and Practice
The complex relationship between depression, health problems, child health problems,
financial strain, and food insecurity is compelling and is further compounded when participants
perceive that they are “getting the run-around” from medical and social service providers. In
other words, these rural low-income mothers suffering from multiple morbidity (including
depression) and multiple other stressors did not benefit from the support of formal safety nets in
their communities. This finding from both studies has implications for research, policy, and
better coordination of services and programming for depressed mothers and their families.
First, more research is needed on the relationship between multiple morbidity and
disability determination. The Social Security Administration (SSA) follows a multi-step process
to determine eligibility for both social security disability (SSD) benefits and supplemental
security income (SSI) benefits (Noblitt & Noblitt, 2010). More data are needed about barriers to
approval when applicants suffer multiple morbidity involving depression. Primary physicians
and psychologists are often called to either provide documentation or conduct a consultative
examination (Wittenburg, Steinagle, Frost & Fine, 2012), however, in an assessment of the

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consultative examination (CE) process, Wittenburg and colleagues (2012) found that none of the
CE providers in their sample were the treating providers in the disability claims. In other words,
the health care professionals in their sample who conducted consultations for disability
determination did not really know the patients. More research is needed to understand how often
primary care physicians and psychologists conduct CEs (compared to providers who are
contracted by Disability Determination Services within the states), and the influence that
frequency has on approval and denial rates. In addition it would be important to investigate the
knowledge and attitudes physicians and psychologists have about multiple morbidity involving
depression, the disability determination process, and their roles as advocates for their patients
(Gask, 2013; and Simmons, Huddleston-Casas, & Berry, 2007).
Second, the findings of this dissertation are consistent with Moussavi, Chatterji, Verdes,
and Tandon, et. al. (2007), who used data from the WHO World Health Survey to determine that
depression had the largest effect on worsening health scores compared to other chronic
conditions tested. That is, compared to angina, arthritis, asthma and diabetes, “the comorbid
state of depression incrementally worsens health compared with depression alone, with any of
the chronic diseases alone, and with any combination of chronic diseases without depression” (p.
851). The findings confirm that regardless of causal direction, it is important to consider health
problems and the history of depression when disability determinations are made. The U.S.
Department of Health and Human Services has stated that major depression is the leading cause
of disability in the United States (1999), yet there were depressed mothers in this sample with
multiple health problems in addition to depression, who were not approved for disability
benefits. The multi-step process that the Social Security Administration (SSA) follows to
determine eligibility for SSD and SSI benefits (Noblitt & Noblitt, 2010) is long and exhausting,

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and many people are denied. In 2006, only 33.7% of total SSD and SSI applications were
granted benefits (Noblitt & Noblitt, 2010). Physicians and other health and mental health
professionals are an important part of the determination process. However, despite multiple
health and mental health problems, several mothers in this sample reported that they were either
denied SSD/SSI benefits, or that their physicians did not advocate for them in the SSD/SSI
determination process. Better policies are needed at the federal and state levels to reduce barriers
to much needed SSD/SSI resources and create avenues so that physicians may better advocate
for their patients.
Third, better communication systems between medical and social service agencies also
need to be developed to help identify gaps in services and connect patients/clients with more
effective formal and informal support systems, especially in rural areas. That depression and
health problems are highly interrelated points to a need to educate physicians (Gask, 2013) and
other health and social service professionals on the importance of consistent screening for
depression among patients with multiple health problems, and to screen parents of children who
have multiple health problems. Previous findings from the Rural Families Speak project indicate
that rural low-income mothers are less likely to self-report depression (Simmons & HuddlestonCasas, 2007), which suggests that many of these women do not get education on access to
services that may help them and their families.
From an ecological perspective, it may be that women in these communities do not feel
valued or heard by health and social service supports. The struggles the women in the present
studies described in relation to accessing formal sources of support indicate a need for
investigation of gender biases that may be inherent in the decision making policies and practices
of health and social service systems, both at the local community level and macrosystem level.

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Findings of such an investigation could have implications for more inclusive gender-valued
service delivery systems.
Last, it is apparent from the findings from both studies that having a perception of
parental and family strengths is important for resilience processes. In addition, perceived social
support plays a crucial role in that women and families experiencing bonadaptation actively
tapped into strong social support networks, while those experiencing maladaptation perceived
themselves and their families as having little to no access to social support. An action-oriented
focus of “tapping into” internal strengths and external supports points to the interactive nature of
development (Bronfenbrenner, as discussed by Tudge, Mokrova, Hatfield & Karnik, 2009) and
resilience processes (Masten & Powell, 2003) and emphasizes an empowered, active role in
mothers’ own parental growth. It is imperative that clinicians and therapists and family life
educators focus on parenting, marital relationships and general relational skills that will
empower mothers with depression vulnerabilities to build healthy attachment cognitions and
healthy social support systems. Inclusion of family members also is important, particularly
spouses or partners, in order to strengthen relational skills and adaptability within the family
system. Clinicians and other professionals undertaking such a task must possess a
comprehensive understanding of the complex nature of depression and the way it plays out in
families.
From a social and health services standpoint, programming and policy that places cultural
and contextual understanding at the center of service delivery (Parra-Cardona, Bulock, Imig,
Villarruel & Gold, 2006; Ungar, 2010) is important for identifying depressed individuals and
families experiencing multiple, interrelated stressors. A cultural lens can help professionals
identify ways in which cultural values and experiences may influence clients’ perceptions of

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formal community supports. In addition, service providers and stakeholders are needed who
understand that depression and multiple health problems compound financial stress and
exacerbate strains in relationships and family functioning. Physicians sensitive to such issues are
helpful when they are willing to complete necessary forms and advocate in court to help connect
patients with needed resources (e.g., disability determination forms and hearings). In addition,
family life educators placed within health organizations can help individuals and families
establish networks of formal support.

Lessons Learned
The lessons learned in the process of planning, conducting and writing this dissertation
research can be discussed from two differing perspectives: the lessons learned from the research
process and findings, and the lessons learned in this very personal journey of growth. This
section will discuss both.
In terms of the research process and findings, this author found that mixed methods
research is an arduous challenge, but well worth the effort. The ways in which the quantitative
and qualitative findings complemented each other provided depth, and richness to the
dissertation as a whole. Nuances of the mother’s lives were highlighted in ways that provided an
opportunity to truly connect with the challenges these women faced. Their realities were a
reminder that much more needs to be done in this field. One of the findings that this author
appreciated was the “action-oriented” way with which many of these women tackled challenges
and worked with their families to forge ahead, even when the challenges seemed insurmountable.
In terms of the second perspective of lessons learned, this dissertation proved to be a
personal journey for this author that is very much related to the finding just discussed. Perhaps

161

that is why it was so easy to connect with this sample and with their lives. This author’s personal
journey of writing this dissertation took much more time than anticipated. Family health
problems, employment, and financial issues continuously interfered with progress, beginning
shortly after the approval of the dissertation proposal. There were many points in which it was
easy to identify with the women in each of the depression patterns, the risk and the resilience. It
is in that respect that the theme pictures of resilience rings so true when reflecting upon this
research, professional and personal journey. Yet the close of this journey signifies the beginning
of another exciting adventure.

Conclusions
The mixed methods and longitudinal design of the two studies provided a methodological
structure for analyzing both quantitative and qualitative data in relation to depression patterns
identified in this sample of rural low-income women. The findings brought about a better
understanding of the ways risk and protective factors organize themselves among longitudinal
depression patterns, and valuable insight to the complex nature of depression and the ways
patterns of depression can play out in the context of rural low income families.
The design of the studies allowed for unique nuances of resilience processes within each
depression pattern to be observed, both at the individual and family levels. The additive and
interactive nature of the sources of stress suggested a metaphor of a “swirling vortex,” which was
especially compelling for women in the high, worsening and erratic patterns. On the other hand,
the ability of many of the mothers to actively tap into sources of strength must be emphasized.
The findings from both studies illuminated the interactive nature of personal characteristics for
garnering and tapping into internal and external sources of strength to off-set or cope with

162

stressful life circumstances. Additionally, the role that culture played among the two women of
Mexican origin brought forth new insight into an important cultural value, familismo, and its
relationship with resilience. Together, these findings highlighted nuances of resilience processes
that help to build upon a resilience framework.

163

APPENDICES

164

APPENDIX A

Wave One Survey Protocol

165

Interviewer: _________________________

ID: ___________________
Date: __________________

PARENT INTERVIEW PROTOCOL
YEAR 1
Thank you for agreeing to participate in this important research on family life. As you probably
know, we are part of a big study that is looking at how families living in rural parts of the
country are managing on a limited income. We are talking to families living in small towns and
rural areas all over the United States. Not all of the families we will talk to are currently
receiving welfare. In fact, we will talk to some families who have never received cash assistance
from the government, but nevertheless have trouble making ends meet each month. There are no
“right” answers to any of our questions; we just want to hear what life is like for you and your
family. Remember, this interview is voluntary. If you don’t want to answer a question, you don’t
have to. All information you give us will be kept confidential. (Do not proceed unless you have a
completed informed consent document.)
Let’s begin by talking about who lives in your household. Besides you, who lives in your house?

CURRENT HOUSEHOLD COMPOSITION
A. Mother’s 1st Name_______________________ DOB________
Marital Status*____ Ethnicity** ______
B. Partner’s 1st Name_______________________ DOB________ Ethnicity**_______
Child
1st (name)

Sex

1. _________ ___
2. _____________
3. _____________
4. _____________
5. _____________
6. _____________

DOB Relation
to A***

Relation
to B***

____
____
____
____
____
___

________
________
________
________
________
________

______
______
______
______
______
______

166

Contact
w/bio
parent
(Y, N)
_________
_________
_________
_________
_________
_________

Receives
child
support
(Y, N)
______
______
______
______
______
______

* Key to codes
** Key to codes
*** Key to codes
S
= Single
W = Non-Hispanic White A
= Adopted
M
= Married
H
= Hispanic/Latino
SC = Stepchild
LWP = Living with partner AA = African American
B
= Biological
child
D
= Divorced
N
= Native American
F
= Foster child
SEP = Separated
A
= Asian
NR = Not related
M = Multi-racial
O
= Other
O
= Other
Do you have any children not currently living with you? (If yes) Who are they, and where are
they living?
OTHER HOUSHOLD MEMBERS
Relationship to A
________________
________________
________________

Length of Time in Household
Arrangement
________________________
________________________
________________________

Permanent or Temporary
_______________________
_______________________
_______________________

Interviewer Notes:

LIVING IN THE COMMUNITY
1. Tell me about how this neighborhood/area is as a place to live. Does this neighborhood/area
have everything that you and your family need? If not, what sorts of things are missing?
(Probe if necessary: Do you have easy access to a grocery store; a mini-mart or convenience
store; other household shopping; medical care; a gas station; church; school; child care; a
library?)
2. Families may need to know how to find many different services available in the community.
The services needed are different for each family. I have a list of resources that are often
available in communities. I’d like to know about the kinds of community services you know
about. Shall I read the list to you, or would you like to fill this out yourself? (Administer:
Knowledge of Community Resources Measure)
NOTE: IF THE INTERVIEWEE ASKS YOU TO READ THE MEASURE, ASSUME THAT
ALL FURTHER SURVEY MEASURES SHOULD BE READ ALOUD.
3. What’s the best thing about living where you do? The worst?
167

4. Is your housing adequate for you and your family’s needs? Why or why not? (Probe: size,
quality, price, landlord.)
5. Have you moved in the past two years? If so, why? How does this place compare with where
you lived before? (If not addressed) How has your family responded to these changes? How
do you feel about this?
6. (Optional, ask if not addressed in #5) Have you ever had a time in the last two years when
you and your family were homeless? For how long were you homeless? What did you do?
How did you get housing again?
1. Let’s talk about your employment situation. Are you currently working? (If not employed,
skip to Question #2) What do you do? How much are you paid? When did you start
working there? How many hours do you generally work each week? How many weeks do
you work during the year? Have you ever had a raise? When? How much? (List only
current employment; space provided for up to three jobs.)
Participant’s Current Employment
Wage/salary
Job 1_____
Job 2_____
Job 3_____

Date started

Hours/week

Weeks/year

__________
__________
__________

__________
__________
__________

__________
__________
__________

__________
__________
__________

Amount
raise
_________
_________
_________

2. (Ask only if not currently employed) Are you looking for a job now? (If yes) How are you
going about it? Have you ever worked for pay? (If answer is no, ask the appropriate
questions in this section, but skip work history section)
3. What about your partner? What does your partner do? How much is your partner paid?
When did your partner start working there? How many hours does your partner generally
work each week? How many weeks does your partner work during the year? Has your
partner ever had a raise? When? How much?
Wage/salary
Job 1_____
Job 2_____
Job 3_____

Partner’s Current Employment
Date started Hours/week Weeks/year

__________
__________
__________

__________
__________
__________

__________
__________
__________

__________
__________
__________

Amount
raise
_________
_________
_________

4. Is there anyone else in the household who has a job? (If yes) Tell me about that.
168

5. (Ask if currently employed) What problems, if any, do you currently face at work?
6. (Ask if currently employed) Do you get any benefits from your job(s)? How about your
partner? What about health insurance…
Benefit
Health insurance for self
Health insurance for children
Sick leave
Vacation pay
Overtime
Retirement plan

Provided by Mother’s Job(s)







Yes
Yes
Yes
Yes
Yes
Yes








No
No
No
No
No
No

Provided by Partner’s Job(s)







Yes
Yes
Yes
Yes
Yes
Yes








No
No
No
No
No
No

7. What would be your ideal job for supporting your family? What would help you to get that
kind of job?
8. In the last several years welfare regulations have changed. There is now more of an
emphasis on getting a job, and there are now time limits (talk about specific state programs,
if appropriate). What do you think about these changes? Has your family been affected by
them?

WORK HISTORY
1. We also want to know about the kinds of work that people have done in the past. Tell me
about your work history. How old were you when you got your first job?
2. About how many jobs do you think you’ve had since then? Have you been more likely to
work full-time or part-time? Why?
3. What kinds of jobs did you have? What were some of the reasons you left these jobs?
4. Tell me about the job that you held the longest, not counting your current job. When did you
have this job? What did you do? What did you like about it? Why did you leave?

169

TRANSPORTATION AND CHILDCARE
1. What about transportation? How do you usually get around? (If not addressed: Do you own a
car or have one you can borrow? How do you and your partner get to and from work?)
a. (If the family has no car) How do you get your groceries, take your children to the
doctors, run errands?
b. (If the family has a car) How reliable is your car? When was the last time your car broke
down? What happened?
2. What do you do when you really need transportation and it’s not available to you?
3.

When you are working (or participating in a job training program or the state’s welfare-towork activities) who takes care of your children? Tell me how you get them there, and about
how long they stay every day. Is it different if you have to work evenings or weekends?

4. (If appropriate) What about your older children? What do they do after school? What about
school holidays and summers?
5. How many childcare arrangements do you have each week/month? Overall, how much do
you pay for childcare each month?
6. How do you like your childcare provider? Why do you feel this way? Have you ever
changed providers? Why?
7. Is there ever a time when you need someone to take care of your children outside your time
at work? Who does that? How does it go?
8. Tell me about a situation when you needed emergency childcare. What did you do? Have
you ever had to miss work or a training program because of a childcare problem? How did
your supervisor react?
9. What do you do for childcare if your child gets sick? What happens if your provider is sick?

Family of Origin Characteristics
1. Tell me a little bit about your background. What was your family like when you were
growing up? Who was in your family? Where did you live? What do you remember about
your childhood?
2. Did your parents work? What kind of work did they do?

170

3. How much education did your mother have? _______ Your father? _______
1 = 8th grade less
2 = some high school
3 = high school or GED
4 = specialized technical, business or vocational training after high school
5 = some college, including AA
6 = college or university graduate
7= one or more years beyond college
8= graduate degree
9 = don’t know
4. Do you know if your family ever received welfare or other assistance?
 Yes
 No
 Don’t Know
5. How often did your family move when you were a child? Why did you move?
6. (Optional) How much contact do you have with your family now? Who are you in contact
with? Where do they live? What is your relationship like now?

FAMILY WELL-BEING
1. Tell me about a typical day (a working day, if appropriate). What time do you get up? When
do your children get up? Then, what happens next? And then…? (The goal here is to get
through a typical weekday for the family.)
2. What sorts of things do you do for fun with your family? How often do you get to do them?
3. Overall, how would you say things are going for your family right now? (If not addressed)
How are things going for you personally? (If appropriate) How are things going between you
and your partner?
4. Here is a checklist that asks about how things have been in the last week. (Administer:
Feelings About How Things Are Going)
5. Parents need lots of skills to help their families get by. Everyone has certain skills and
abilities, but it’s usually not possible for someone to have every single skill needed. We’d
like to know what sorts of skills you have. (Administer: Life Skills Assessment)
6. Family members often have health problems. Sometimes these problems don’t have much of
an impact on day-to-day life, while at other times they can be a big problem. We’d like to
know about any health problems the members of your family might have. (Administer: Adult
Health Survey; Administer: Child Health Survey; use more than one if needed to get info
about all children)

171

7. (If there are other people living in the household) Do any of the other people in your
household have any health problems? (If yes) What kinds of health problems?
8. (If applicable) Do any of these health problems affect everyday life in your family? If so,
how?
9. What things about your family make you proud and happy right now? What are the biggest
challenges for your family as a whole?

EDUCATION AND INCOME
1. What is your current educational level? _____ (use scale below)
1= 8th grade less
2 = some high school
3 = high school or GED
4 = specialized technical, business or vocational training after high school
5 = some college, including AA
6 = college or university graduate
7 = one or more years beyond college
8 = graduate degree
9 = don’t know
2. How much education did you have when you first became a parent? ____ (use scale)
3. (If no high school diploma) Why did you leave high school before finishing?
4. (If appropriate) What about your spouse/partner-how much education does he have?____
(scale)
5. In the last few years have you had the opportunity to get further education or develop new
job skills? What kind? How were you able to do this?
6. We’d like to know a bit about your family’s sources of income. Remember, all of this
information is completely confidential. From which of the following sources do you receive
income?
Source of Income
Wages and salaries (self)
Wages and salaries (partner)
Tips, commissions, overtime
Social Security Disability
Social Security
Retirement/Pensions
SSI (Supplemental Security
Income)

Take Home Pay
________
________
________
________
________

Weekly






Bi-Weekly






Monthly






________







172

Source of Income
TANF
Unemployment Compensation
Worker’s Disability
Compensation
Veterans’ Benefits
Child or spousal support
Children’s wages
Food Stamps
Regular gifts from
family/friends
Other:

Take Home Pay
________
________
________

Weekly




Bi-Weekly




Monthly




________
________
________
________
________



















________







7. Housing is usually the largest expense for families. Tell me about how much you pay per
month and what utilities, if any, are included. Is this a rental or do you own? What utilities do
you pay each month? How much? What happens when you can’t pay for utilities?
8. Families sometimes receive assistance from a variety of government or private programs. Do
you receive assistance from any of the following?
 WIC
School Lunch Program
 EIC (Earned Income Credit)
Child Care Assistance
 Housing Assistance
 Energy/Fuel Assistance

 Transportation Assistance
 Diversionary Assistance (only some states)
 Educational Grants or Loans
 Medicaid/ MA
 Other

9. Is there any other assistance you’re getting, such as help with healthcare, food, meals,
clothing, holiday gifts, furniture, baby goods, day care, or school supplies?
Type of help

Amount

Type of help

Amount

______________________ ________ ______________________ ________
______________________ ________ ______________________ ________
______________________ ________ ______________________ ________
10. Compared to two years ago, would you say your family’s economic situation has:
5 = Improved a lot
4 = Improved a little
3 = Remained the same
2 = Gone down a little
1 = Gone down a lot
11. (Optional)To what extent do you think your income is enough for you to live on?
173

1 = Not at all adequate
2 = Can meet necessities only
3 = Can afford some of the things we want but not all we want
4 = Can afford about everything we want
5 = Can afford about everything we want and still save money
12. In past year, has there been a time when you had a hard time making ends meet or paying for
necessities? What did you have trouble paying for? Food? Clothing? Healthcare? Credit
payments? Personal care or non-food items? (If appropriate) Diapers? What did you do?

Item
Food
Clothing
Medical Care
Dental Care
Medicines
Credit Payments
Personal Care Items
Diapers
School Fees or
Expenses
Past Bills:
Other:

Yes










No
















13. Have you or members of your household ever gone hungry or been close to going hungry?
Please describe the situation as fully as you can. What led to it? How did you deal with it?
14. What do you need most to prevent this situation from happening again? (Administer Food
Security Module)
15. When you’ve gone for help from an agency, how were you treated? (Probe for specific
agencies.)
16. In the past year, have you sold or pawned anything you owned?

PARENTING
1. Let’s talk about being a parent. What do you enjoy most about being a parent? What are
your strengths as a parent? What is the hardest part of being a parent?
2. (If appropriate) How does your partner help you with parenting?

174

3. (Optional) Here’s another checklist that asks you to describe how you feel about yourself as a
parent. (Administer: Parent Ladder)

SOCIAL SUPPORT
1. Who are the people who are most important to you and your family? By this, we mean
friends or relatives who are important to you for one reason or another. For each person ask:
Who is this person? Why are they important to you? (If appropriate) How did you meet
them? How often are you in contact with them? Is there anyone else?
2. Is there anyone who makes things hard for your family? How so? Tell me about that.
3. Do you ever get to go out with your friends? Have you been able to find the time for any
outside activities? What sorts of things do you do?

SUMMARY
1. When you look back over the past few years, what do you think are the most important things
that have happened to you and your family?
2. Looking ahead into the future, what are you most looking forward to in the coming year?
What do you most worry about? What do you think things will be like for your family in
three years?
3. Overall, how satisfied are you with your life right now? (Use scale below) Why do you feel
that way?
1 = very dissatisfied
2 = dissatisfied
3 = mixed feelings
4 = satisfied
5 = very satisfied
4. Is there anything else that you think we should know about how your family is doing right
now? Is there anything we’ve missed?

175

CONTACT INFORMATION: TO BE REMOVED AND KEPT IN STATE FILES
As you know, we would like to visit with you again in a few months to see how your family is
doing. To make it easier to contact you in case you move and forget to tell us, will you share the
name and phone numbers of three people who will always know where you are? Please be sure
to tell them that we may contact them.
Name

Phone Number

___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________
Thank you so much for your time.
NOTE

176

There are many community services that families need to know how to access. The services
needed are different for each family. If you needed it, would you know where to go to:
Table A.1. Knowledge of Community Resources
Service

Yes

1.

Get help on heating bills

2.

Apply for subsidized housing

3.

Find temporary housing

4.

Apply for Medicaid

5.

Find help for a drug or alcohol problem

6.

Find help for a domestic violence problem

7.

Get your child immunized

8.

Find a family doctor

9.

Find dental care

10

Find a mental health counselor

11.

Find family planning services

12.

Apply for welfare

13.

Get legal assistance

14.

Apply for food stamps

15.

Apply for WIC

16.

Locate job training

17.

Find transportation choices

18.

Find child care

19.

Apply for a child care subsidy

20.

Find help for a family member with disabilities

21.

Find low-cost clothing for your family

22

Find Cooperative Extension Activities (EFNEP,

177

No

Table A.2. Life Skills Assessment
Do you have:
1.

A driver's license

2.

Car insurance

3.

Car registration

4.

Heath insurance

5.

A checking account

6.

A good credit record

7.

Yes

A local library card

Do you know how to:
8

Manage your bills

9

Write a personal check

10

Make a family budget

11.

Stretch your groceries to the end of the month

12.

Register to vote

13.

Apply for a credit card

14.

Prepare a well-balanced meal for your family

15.

Get telephone service

16.

Work with your landlord to improve housing

17.

Register a consumer complaint

18.

Talk to your child's teacher

19.

Fill out forms to apply for services

20.

Apply for a job

21.

Write a resume

22.

Dress for a job

23.

Fill out your own income tax forms

24.

Join a local club or organization

25.

Create a personal support system

178

No

For each of the following statements, check the box that best describes HOW OFTEN YOU
HAVE FELT THIS WAY DURING THE PAST WEEK.
Table A.3. Feelings About How Things Are Going
Rarely or
none of
the time

A little
of the
time

A moderate
amount of
time

Most or
all of
the time

1. I was bothered by things that
don’t usually bother me
2. I did not feel like eating; my
appetite was poor
3. I felt that I could not shake the
blues even with help from my family
and friends
4. I felt that I was just as good as
other people
5. I had trouble keeping my mind on
what I was doing
6. I felt depressed
7. I felt that everything I did was an
effort
8. I felt hopeful about the future





























































9. I thought my life had been a
failure
10. I felt fearful
11. My sleep was restless
12. I was happy
13. I talked less than usual
14. I felt lonely
15. People were unfriendly
16. I enjoyed life
17. I had crying spells
18. I felt sad
19. I felt that people disliked me
20. I could not “get going”

























































179

Figure A. 1. The Parenting Ladder
6 High
5
4
3
2
1
0 Low

Where would you put yourself on the Parenting Ladder in terms of:
Your knowledge of how children grow and develop?

_________

Your confidence that you know what is right for your child?_________
Your ability to create a safe home for your child?

_________

Your success in teaching your child how to behave?

_________

Your skill at finding fun activities that interest your child? _________
The amount of stress in your life right now?

_________

Your ability to cope with the stress in your life?

_________

Parenting is often smoother when others are there to help. Where would
you put yourself on the Parenting Ladder in terms of:
Other parents for you to talk to?

_________

Someone to help you in an emergency?

_________

Someone to offer helpful advice or moral support?
Someone for you to relax with?

____
_________

Professional people to talk to when you have a question
about your child?

_________

Your overall satisfaction with the amount of support
in your life?

_________

180

ADULT HEALTH SURVEY
Do you and/or your partner
have medical insurance?
You Yes_____ No_____
Partner Yes_____ No_____
If yes, what kind?

Private/HMO

Medicaid/MA

State Health Plan

Other (Explain)
_____________________
Do you and/or your partner
have any type of dental
insurance?
You Yes_____ No_____
Partner Yes_____ No_____
If yes, what kind?

Private

Medicaid/MA

Other (explain)

About how many times in
the past year have you
been to a doctor or
other health care
provider?
_____________________
_____
Your
partner?______________
____
If none, when was the last
time you visited a doctor
or health care provider?
_____________________
Your
partner?______________
About how many times in
the past year have you
visited a
dentist?_______________
Your
partner?______________
If none, when was the last
time you did visit a
dentist?

Your
partner?______________

Have you or your
partner had any
injuries or serious
illnesses in the past
year?
You Yes _____
No _____
Partner Yes _____
No _____
If yes, please explain
_________________
_________________
_________________
About how many
times in the past year
have you missed
work due to an
illness/injury?
_______________
Your
partner?_________
Have you been
pregnant in the past
three years
Yes_____ No_____
If yes: How many
times__________
Are you and your
partner able to have
more children?
Yes_____ No_____
If so, do you
currently use birth
control?
Yes_____ No_____

181

In the past three years, have you or your partner experienced any of the following
health problems?
You
Heart Problems

High Blood Pressure 
Diabetes

Cancer
Digestive
Problems
Liver Problems
Seizure Disorder
Depression/Anxiety

Partner


















Joint Problems
Chronic Pain
Eating Disorder/
Obesity
Skin Problems
Permanent Disability
Sexually Transmitted
Disease
Reproductive
Problems
Bladder Infections
Drug Problem
Alcohol Problem
Tobacco Use

Anger Management 

Hepatitis


Allergies


Asthma


Frequent colds/
flu/sinus


Anemia
Thyroid Problems


Emotional, physical,
Kidney Problems


or sexual abuse
Fatigue


Migraines/Headaches
Eye or vision
problems


Learning Disabilities
Back Problems


Arthritis
Other (specify)____________________________________

182

You



Partner











































First name of: Child 1:________________ Child 2: ________________
Child 3: ________________
CHILD HEALTH SURVEY
Does C1 have medical
insurance?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
___________________
__________
C2:  Yes  No If yes,
what kind?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
___________________
__________
C3:  Yes  No If yes,
what kind?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
___________________
__________
About how many times
in the past year has your
child been to a doctor or
other health care
provider?
C1 _______ C2 ______
C3 _______

Does C1 have any type of
dental insurance?  Yes 
No If yes, what kind?

Private

Medicaid/MA

Other (Explain):

If none, when was the
last time your child
visited a doctor or health
care provider?
C1 ______ C2 _____
C3 ______

C1 ________ C2 _______
C3 ______

C2:  Yes  No If yes, what
kind?

Private

Medicaid/MA

Other (Explain):
__________
C3:  Yes  No If yes, what
kind?

Private

Medicaid/MA

Other (Explain):

About how many times in
the past year has your child
visited a dentist?
C1 _______ C2 _______ C3
______
If none, when was the last
time your child did visit a
dentist?

183

Has your child had
any injuries or
serious illnesses in
the past year?
C1:  Yes No
C2:  Yes No
C3:  Yes No
If yes, please
explain___________
_________________
_________________
_________________
_________________
_________________
_____________
About how many
times in the past year
has your child missed
school due to an
illness/injury?
C1: _________
C2: _________
C3: _________

In the past three years, has your child experienced any of the following health problems?
C1
Allergies

Anemia

Asthma

Cancer

Chronic Pain

Learning Disability 
Depression/Anxiety 
Anger Management 
Diabetes

Digestive Problems 
Drug Problem

Alcohol Problem

Ear Infections

Eating Disorder/
Obesity

Eye or vision

Fatigue

Frequent colds/flu/
sinus 
Hepatitis

Seizure Disorders

Skin Problems


C2














C3



























C1








Head Lice
Behavior Problems
Conjunctivitis
(pink eye)

ADD/ADHD

Fetal Alcohol Effects/
Syndrome

Fetal Drug Effects

Broken Bones

Sexually Transmitted
Disease

Skeletal Problems

Tobacco Use

Migraines/Headaches 
Permanent Disability 
Other (specify)

184

C2



C3





























FOOD SECURITY MODULE
These next questions ask about the food eaten in your household in the last 12 months, since
(current month) of last year, and whether you were able to afford the food you need.
1. Which of these statements bests describes the food eaten in your household in the last 12
months:
[1] Enough of the kinds of food we want to eat (SKIP 1a and 1b)
[2] Enough but not always the kinds of foods we want (SKIP 1a)
[3] Sometimes not enough to eat (SKIP 1b)
[4] Often not enough to eat (SKIP 1b)
[ ] DK or Refused (SKIP 1a and 1b)
1a.

[IF OPTION 3 OR 4 SELECTED, ASK] Here are some of the reasons why people don’t
always have enough to eat. For each one, please tell me if that is a reason why YOU
don’t always have enough to eat. [READ LIST. MARK ALL THAT APPLY.]
YES







1b.

NO







DK






problems

Not enough money for food
Not enough time for shopping or cooking
Too hard to get to the store
On a diet
No working stove available
Not able to cook because of health

[IF OPTION 2 SELECTED, ASK] Here are some reasons why people don’t always have
the quality or variety of food they want. For each one, please tell me if that is a reason
why YOU don’t always have the kinds of food you want to eat. [READ LIST. MARK
ALL THAT APPLY.]
YES






NO






DK






Not enough money for food
Kinds of food we want not available
Not enough time for shopping or cooking
Too hard to get to the store
On a special diet

2. Now I’m going to read you several statements that people have made about their food
situation. For these statements, please tell me whether the statement was often true,
185

sometimes true, or never true for your household in the last 12 months, that is, since last
(name of current month).
The first statement is “We worried whether our food would run out before we got money
to buy more.” Was that often true, sometimes true, or never true for your household in
the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
3. “The food that we bought just didn’t last, and we didn’t have money to get more.” Was that
often, sometimes or never true for your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
4.

“We couldn’t afford to eat balanced meals.” Was that often, sometimes or never true for
your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused

5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/ren because (I
was/we were) running out of money to buy food.” Was that often, sometimes or never true
for your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
6. “(I/We) couldn’t feed (my/our) child/ren a balanced meal, because I couldn’t afford that.”
Was that often, sometimes or never true for your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
If answer “often true” or “sometimes true” to any one of Questions 2-6, or response [3] or [4] to
Question 1, then ask questions 7-16, otherwise stop here.
7. “(My/Our child was/The children were) not eating enough because (I/we) just couldn’t afford
enough food.” Was that often, sometimes or never true for your household in the last 12
months?
186

 Often True
 Sometimes True
 Never True
 DK or Refused
8. In the last 12 months, since last (name of current month), did you (or other adults in your
household) ever cut the size of your meals or skip meals because there wasn’t enough money
for food?
 Yes
 No (Skip 8a)
 DK (Skip 8a)
8a. [IF YES ABOVE, ASK] How often did this happen—almost every month, some months but
not every month, or in only 1 or 2 months?
 Almost every month
 Some months, but not every month
 Only one or 2 months
 DK
9. In the last 12 months, did you ever eat less than you felt you should because there wasn’t
enough money to buy food?
 Yes
 No
 DK
10. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford
enough food?
 Yes
 No
 DK
11. In the last 12 months, did you lose weight because you didn’t have enough money for food?
 Yes
 No
 DK
If any answer to Question 7-11 is affirmative, continue, otherwise stop here.

12. In the last 12 months did (you/you or other adults in your household) ever not eat for a
whole day because there wasn’t enough money for food?
 Yes
 No (Skip 12a)
 DK (Skip 12a)
187

12a. [IF YES TO 12, ASK] How often did this happen—almost every month, some months, but
not every month, or in only 1 or 2 months?
 Almost every month
 Some months, but not every month
 Only one or 2 months
 DK
13. The next questions are about children living in the household who are under 18 years old. In
the last 12 months, since (current month) of last year, did you ever cut the size of (your
child’s/any of the children’s) meals because there wasn’t enough money for food?
 Yes
 No
 DK
14. In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals because
there wasn’t enough money for food?
 Yes
 No (skip 14a)
 DK (skip 14a)
14a. [IF YES ABOVE, ASK] How often did this happen—almost every month, some months but
not every month, or in only 1 or 2 months?
 Almost every month
 Some months, but not every month
 Only one or 2 months
 DK
15. In the last 12 months, (was your child/were the children) ever hungry but you just couldn’t
afford more food?
 Yes
 No
 DK
16. In the last 12 months, did (your child/any of the children) ever not eat for a whole day
because there wasn’t enough money for food?
 Yes
 No
 DK

188

APPENDIX B

Wave Two Survey Protocol

189

Interviewer_________________________ ID:______________ Date:_______________
PARENT INTERVIEW PROTOCOL
YEAR II
I want to thank you for agreeing to be interviewed again this year. Just like last time, there are
no right or wrong answers to any of our questions. We are interested in hearing what life is like
for you and your family. I want to remind you that the interview is voluntary. If you do not
want to answer a question, you don’t have to. All information that you give us will be kept
confidential. [DO NOT PROCEED UNLESS PARTICIPANT HAS SIGNED THE INFORMED
CONSENT FORM.]
{NOTE TO INTERVIERWER – ALWAYS ASK QUESTIONS IN OPEN-ENDED MANNER
FIRST, DON’T JUST READ OFF A LIST OF YES/NO QUESTIONS. USE THEIR
ANSWERS TO THE OPEN-ENDED QUESTIONS TO FILL IN THE YES/NO BOXES AND
THEN PROBE WHEN NECESSARY TO GET INFORMATION. PLEASE MAKE SURE
THAT YOU FILL IN ALL BLANKS AND CHECK ALL BOXES ON THIS FORM.}
CURRENT HOUSEHOLD COMPOSITION
Mother’s 1st Name_______________________
We’d like to catch up on any changes in your life and in your family since the last time we talked
with you.
{PULL THE APPROPRIATE INFORMATION FROM THE WAVE 1 INTERVIEW.}
Last year, you said that
_________________________________________________________________
were living in your household.
Is this still true? Yes  No 
Is there any one new living in your household? Yes  No 
Who? {FILL IN CHART FOR NEW CHILDREN, FILL IN SECTIONS BELOW FOR PARTNERS
AND NON-PARTNERS}
[IF CHILD MOVED OUT]
When? Why? Where is child living now?

190

New Child
name)

Sex

DOB

Relation
Relation
Contact w/ Receives (first
Mother
Partner/
bio parent child support
Spouse
(Y, N)
(Y, N)
1. __________ ____ ________ ___________ __________ ________ __________
2. __________ ____ ________ ___________ __________ ________ __________
3. __________ ____ ________ ___________ __________ ________ __________
* Key to codes
**Key to Codes
S
= Single
W =Non-Hispanic White
M
= Married
H =Hispanic/Latino
LWP = Living with partner AA =African American
D
= Divorced
N =Native American
SEP = Separated
A =Asian
M =Multi-racial
O =Other

*** Key to codes
A = Adopted
SC = Stepchild
B = Biological child
F = Foster child
NR = Not related
O = Other

B. Last year you told us you were {married, separated, divorced, single,
living with _______}.
Has that changed? Yes  No  [IF NO, SKIP TO NEXT SECTION]
[IF YES] What is the change? __________________________________________
Did partner moved out? (PROMPT: When? Why?)
 Yes  No
Did a new partner moved in? (PROMPT: How long has partner lived here?)
 Yes  No
New Partner’s 1st Name__________________
Ethnicity**_______

DOB___________

Did a non-partner move out (PROMPT: When? Why?)
 Yes  No
Did a non-partner move in (PROMPT: When? Why? Is it a permanent or temporary
arrangement?)
 Yes  No
What is this person’s relationship to you? ______________________________

191

LIVING IN THE COMMUNITY
1. Are you living in the same place? Yes  No  [IF LIVING IN THE SAME PLACE,
SKIP TO Q2]
[IF NO] How many different places have you lived since we last talked?___________

Tell me what has happened with the places where you lived?
(PROBE: Why did you move? How does this compare to where you used to live? Why
do you think that?)
Are there services close by? Yes  No 
How close?
Do you have easy access to:
Grocery store
Medical care
School
Other

Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 

If not, what is missing or far away?
Tell me about how your move affected your family.
PROBE: How is your family responding to the change? Is the place where you are living
now adequate for your needs?
PROMPT: size, quality, price, landlord.
What’s the best thing about your new place (and/or community)? The worst thing?
Were you without your own housing at any point in the last year? Yes  No 
[IF YES] What happened? How did you find housing again?
Did you live with a relative or a friend during that time?
Yes  No 
There are many community services that families need to know how to access, and what
each family needs may be very different. I would like to know about the kinds of
community services you know about.
[ADMINISTER KNOWLEDGE OF COMMUNITY RESOURCES MEASURE]
[GO TO Q3]
2. [IF THEY ARE LIVING IN THE SAME PLACE]
Has anything changed in your neighborhood this year? Can you tell me about that?
192

What is the best thing about living where you do (community or neighborhood)? What’s
the worse?
Do you feel safe where you live? Yes  No 
Why or why not? What makes it safe/not safe? (Physical safety or otherwise.)
Do you feel that your children are safe? (PROBE to fill in chart)
In your home
Yes  No 
The neighborhood
Yes  No 
At their school
Yes  No 
Why do you feel your children are safe (or unsafe)? Who (relationship) or what is it that
makes you concerned for their safety? Is there anything you can do about it?
3. Why do you choose to live in this area? In this particular unit/apartment/house? In this
town? In this neighborhood? (PROBE: Are family and friends in the area?
Yes  No 
4. Our house or apartment can sometimes have problems (such as plumbing problems or a
leaky roof) that can make things difficult for us and our families.
Can you tell me about any housing problems that you have experienced? (IF NEEDED,
PROBE WITH FOLLOWING)
Leaky plumbing
Faulty electrical system
Exposed wires
Broken heating system
Pests (such as mice, rats, fleas, or cockroaches)
Leaky roof or ceiling
No hot water
Stove or refrigerator that would not work
Environmental problems (such as asbestos,
lead paint, radon, or mold,
broken stairs, doors, etc.?)

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 
No 
No 

Yes  No 

[IF YES TO ANY] Were you able to fix it? Yes  No 
How did you pay for it? How long did the problem last? Did this pose a
difficulty for you and your family?

193

EMPLOYMENT/CURRENT WORK
{IN THIS SECTION, PICK THE SERIES OF QUESTIONS THAT CAPTURES WHAT THE
RESPONDENT, AND PARTNER IF APPLICABLE, WAS/WERE DOING AT THE TIME OF
THE WAVE 1 INTERVIEW. YOU MAY WANT TO ALWAYS LEAVE IN THE QUESTIONS
RELATED TO A NEW PARTNER JUST TO BE SAFE.}
{IF RESPONDENT WAS WORKING LAST YEAR, ASK THE “A” QUESTIONS}
1.
A. Last time we talked you said you were working at ___________.
Are you still working there? Yes  No 
[IF YES] How is your job/work going for you? Has anything changed about your job?
Such as….
Different responsibilities
Yes  No 
Different hours
Yes  No 
Have you had a raise or promotion? Yes  No 
When? How much? ________________
Has the promotion changed your family life in any way (such as new hours or longer
hours)
Is this your only job? Yes  No 
[IF NO] Tell me about your other job(s).
Why did you need another job?
[IF NOT WORKING AT SAME JOB] Can you tell me about what happened with your
other job? (PROBE: Why did you leave the other job?
Are you currently working? Yes  No 
[IF NOT WORKING] Have you looked for work? Yes  No 
[IF LOOKED FOR WORK] How has that gone? [THEN SKIP TO Q2]
[IF NOT LOOKED FOR WORK] What’s kept you from looking? [THEN SKIP TO 2]

194

[IF YES, ARE WORKING] Tell me about the job(s) you have now. (PROBE to fill in
charts: Where are you working now? What is it that you do? Are you working full-time
or part-time?
Wage/Salary Started

Hours/wk

Weeks/yr

Raise

Job 1 ____________ __________

______

________

_______ ______

Job 2 ____________ __________

______

________

_______ ______

(PROBE to fill in chart: Do you get any benefits with this new job(s)?)
Health insurance for yourself Yes 
No 
Health insurance for children Yes 
No 
Sick leave
Yes 
No 
Vacation
Yes 
No 
Overtime
Yes 
No 
Retirement plan
Yes 
No 
How does this job compare to your old job? Why do you say that?
{IF RESPONDENT WAS NOT WORKING LAST YEAR. ASK THE “B” QUESTIONS}
B. Last time we talked, you said you were not working.
Has this changed over the year? Have you looked for work? Yes 

No 

[IF YES] How has that gone?
[IF NO] What’s kept you from looking? [THEN SKIP TO Q2]
[IF WORKING] Tell me about your job(s). (PROBE: How did you find this job? Did you
know someone who already worked there? Where are you working now? What is it that you
do? Are you working full-time or part-time?) (PROBE to fill in charts)
Wage/Salary Started

Hours/wk

Weeks/yr

Raise

Job 1____________ __________

______

________

_______ ______

Job 2____________ __________

______

________

_______ ______

195

(PROBE to fill in chart: Do you get any benefits with this new job(s)?)
Health insurance for yourself Yes 
No 
Health insurance for children Yes 
No 
Sick leave
Yes 
No 
Vacation
Yes 
No 
Overtime
Yes 
No 
Retirement plan
Yes 
No 
2. In the last year, have you had the opportunity to get further education or training?
Yes 
No 
[IF YES] Tell me about that. What kind was it and where did you do it?
How did you pay for it?)
[IF EMPLOYER-SPONSORED] Who else was sent to the training?

(PROBE:

{IF RESPONDENT HAD A PARTNER WHO WAS WORKING AT WAVE 1, ASK THE “A”
QUESTIONS}
3. A. [IF SAME PARTNER AS WAVE 1] Last time we talked, you said
___________{name of person} was working.
Is he (she) still working there? Yes  No 
[IF YES] Has anything changed about his (her) job? (responsibilities,
hours, etc.)?
Has he (she) had a raise or promotion? Yes  No 
When? _____________
How much? ______________
Has the promotion changed your family life in any way (such as new
hours or longer hours)?
[IF NO] Can you share with me what happened and why he (she) is not working
at the same job? (PROBE: Why did he (she) leave the other job?)
Is he (she) currently working? Yes  No 
[IF NO] Has he (she) looked for work? Yes  No 
[IF YES, LOOKED FOR WORK] How has that gone?
[THEN SKIP TO Q5]
[IF NOT LOOKED FOR WORK] What has kept him (her) from looking?
[THEN SKIP TO Q5]
196

[IF YES, CURRENTLY WORKING] Tell me about his (her) current
job(s). (PROBE to fill in chart:
Where is he (she) working now? What is it that he (she) does? Is he (she)
working full-time or part-time?
Wage/Salary Started

Hours/wk

Weeks/yr

Raise

Job 1 ____________ __________

______

________

_______ ______

Job 2 ____________ __________

______

________

_______ ______

(PROMPT to fill in chart: Does he (she) get any benefits with this new job?)
Health insurance for him/herself
Yes 
No 
Health insurance for children
Yes 
No 
Sick leave
Yes 
No 
Vacation
Yes 
No 
Overtime
Yes 
No 
Retirement plan
Yes 
No 
How does this job compare to his (her) old job? Why do you say that?
{IF RESPONDENT HAD A PARTNER WHO WAS NOT WORKING AT WAVE 1, ASK THE “B”
QUESTIONS.}
B. [IF SAME PARTNER AS WAVE 1] Last time we talked, you said _________{INSET
NAME} was not working.
Has this changed over the year? Yes  No 
[IF NO] Has he (she) looked for work? Yes  No 
[IF YES, LOOKED FOR WORK] How has that gone? [THEN SKIP TO Q5]
[IF NOT LOOKED FOR WORK] What has kept him (her) from looking?
[THEN SKIP TO Q5]

197

[IF YES, CURRENTLY WORKING] Tell me about his (her) job(s). (PROBE: How did
he (she) find out about the job? Did he (she) know someone already working there?
Where is he (she) working now? What is it that he (she) does? Is he (she) working fulltime or part-time? (PROBE to fill in charts.)
Wage/Salary Started

Hours/wk

Weeks/yr

Raise

Job 1____________ __________

______

________

_______ ______

Job 2____________ __________

______

________

_______ ______

(PROMPT to fill in chart: Does he (she) get any benefits with this new job?)
Health insurance for him/herself
Health insurance for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

3. [IF THERE IS A NEW PARTNER] Is your partner/boyfriend/spouse employed?
Yes  No 
[IF NO] Has he (she) looked for work? Yes  No 
[IF YES, LOOKED FOR WORK] How has that gone? [THEN SKIP TO Q5]
[IF NOT LOOKED FOR WORK] What has kept him (her) from looking?
[THEN SKIP TO Q5]
[IF YES, CURRENTLY WORKING] Tell me about his (her) job(s). (PROBE: How did
he (she) find out about the job? Did he (she) know someone already working there?
Where is he (she) working now? What is it that he (she) does? Is he (she) working fulltime or part-time? (PROBE to fill in charts.)
Has he (she) ever had a raise? Yes  No 
When? ___________

How much? ____________

Wage/Salary Started

Hours/wk

Weeks/yr

Raise

Job 1____________ __________

______

________

_______ ______

Job 2____________ __________

______

________

_______ ______

198

(PROMPT to fill in chart: Does he (she) get any benefits with this new job?)
Health insurance for him/herself
Health insurance for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

4. Does anyone else in the household have a job? Yes  No 
[IF YES] Tell me about that.
How about a child or children? Yes  No 
[IF YES] What is done with the child’s/children’s earnings?
5. [IF NOT CURRENTLY WORKING]
Since you are not currently working outside the home, is there anything in your life that
makes it more difficult for you to work at all or participate in a training program?
(PROBE to fill in the chart)
Childcare
Health issues
Family issues
Your partner

Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 

Can you tell me more about that?
7. What is your opinion of job opportunities in this area? {ALTERNATIVE WORDING}
From last year until now, what do you think of the job situation in this area? Have there
been any changes?
8. Sometimes people express strong opinions about people who are receiving welfare.
What kinds of opinions have you heard?
What do you think of these opinions?

199

[IF EVER RECEIVED WELFARE] Were any of these things said to you? To your
children? What was the situation? Have you ever felt that you or your children were
treated differently or unfairly because you were on welfare? (PROBE to fill in chart:
Have you or your family ever been….
Refused service
Made to wait
Treated rudely

Yes 
Yes 
Yes 

No 
No 
No 

9. In the last several years, welfare regulations have changed. There is now more of an
emphasis on getting a job, and there are now time limits. For example, families who
have received assistance for five years in a row will not be able to get cash assistance any
longer. Five years will be over for some families at the end of this year. In Michigan,
single parents without children under 6 are required to work at least 30 hours per week.
These changes also apply to immigrants from other countries. New legal aliens are not
able to receive government help for the first five years after they arrive.
Do you feel these rules have affected your family in any way? Yes  No 
Do you talk with anyone about these changes? Family? Friends? {ALTERNATIVE
WORDING} Do you hear things on TV or radio about these changes? Yes  No  [IF
YES] What have you heard?
TRANSPORTATION AND CHILD CARE
{USE INFORMATION FROM WAVE 1 TO CONSTRUCT QUESTION 1.}
{IF HAD VEHICLE IN WAVE 1, ASK 1A.}
1. A. Last time we talked, you said that you had a (reliable car/ unreliable car{INDICATE
WHICH}). Have you had a situation in the last year when you had a problem with your
car/truck{OR WHATEVER TRANSPORTATION SHE HAS}? Yes  No 
Tell me about what happened. What did you do?
Has a friend or relative helped you out? Yes  No 
How do you get around if your car breaks down or is not available to you?
{IF NO VEHICLE IN WAVE 1, ASK 1B.}
1. B. Last time we talked, you said that you usually get around by __________ {USE
INFORMATION FROM WAVE I} Do you still depend on {THIS PERSON/ THIS TYPE
OF TRANSPORTATION}? Yes  No 

200

(PROBE: How do you usually get around? How do you get to work? How do you get
groceries?) (PROBE IF NECESSARY:
Has a friend or relative helped you out? Yes  No 
2. This year the price of gas has gone up and down. Did this change anything in how you
get around? Yes  No 
(PROBE: Have the increases caused you any problems? Yes  No 
What have you done?)
{USE INFORMATION FROM WAVE 1 TO CONSTRUCT QUESTION 3.}
3. [IF APPROPRIATE] Last time we talked, you said that
__________________________________
provided care for your children. Do you still have the same arrangement(s)?
Yes  No  [IF YES, GO TO Q4]
[IF NO] What brought about the changes? Do you have a new child care provider?
(PROBE: How is this working out? How do you like your new child care provider(s)?
How does your child like the provider(s)? (IF MORE THAN ONE PROVIDER,
PROBE: How many? Why more than one?)
{IF RESPONDENT HAS OLDER CHILDREN, ASK QUESTION 4, OTHERWISE OMIT.}
4. [IF APPROPRIATE] What about your older children? What do they do after school?
What about school holidays and summers?
5. Tell me about a situation when you needed emergency childcare. What did you do?
(PROBE: Have you ever had to miss work or a training program because of a childcare
problem? Yes  No  [IF YES] How did your supervisor react? (PROBE IF
NECESSARY: Has a friend or relative helped you out? PROBE: Is there a time when
you needed someone to take care of your children outside your time at work? Who does
that? How does it go?
6. What do you do for childcare if your child gets sick? What happens if your childcare
provider is sick? (PROBE IF NECESSARY: Has a friend or relative helped you out?)
(PROBE IF APPROPRIATE: How did your supervisor react?
7. [IF RESPONDENT IS CURRENTLY WORKING] How is it combining work
responsibilities and family responsibilities? Do you have any problems at home because
of work? Or do you have any problems at work because of family?

201

8. [ONLY FOR MI RESPONDENTS] We have been talking about childcare,
transportation, and a lot of other issues. Can you think for a moment about a list of all of
the things that need to happen in order for you [and/or your partner] to be able to work
for pay. What would you need most to be able to work for pay? What would come next?
[Continue with the list as far as they can.] Is there anything that you have not already
told us about that you need to have or you need to happen in order to be able to work?
(PROBE: Moving for work, commuting, carpooling, child care, housekeeping, new
clothing or uniforms, odd jobs to make enough money, education for a better job, help
from friends or family, …)

9. [ONLY FOR MI RESPONDENTS] Last time, you told us about what your ideal job
would be, the sort of job you would most like to have. What would be an ideal job for
you right now? What would you need to happen for you to get that job and be able to
keep it? (PROBE: moving, commuting, carpooling, child care, housekeeping, odd jobs,
education, training, help from friends or family, …)
10. [IF RESPONDENT IS CURRENTLY WORKING] Is there anything in your life that
makes it more difficult for you to hold down a job (or participate in a training program)?
(PROBE to fill in chart)
Childcare
Yes 
No 
Health issues Yes 
No 
Family issues Yes 
No 
Your partner Yes 
No 
Can you tell me more about that?
FAMILY OF ORIGIN
1. Last year we talked a bit about your family background. In the past year, have there been
any important changes in your relationships with your parents or your brothers and sisters
or other relatives?
2. Has your family experienced any important events in the last year, or is there any family
news that you think we should know about? (PROBE: births, deaths, marriages,
illnesses, etc.)

202

INCOME AND MAKING ENDS MEET
1. We would like to know about your family’s sources of income in the past year.
Remember, all this information is completely confidential. From which of the following
did you receive income this year? (PROBE for changes in TANF, child and spousal
support, food stamps, wages: Has that been the same all year? Tell me about the change.)

Amount
Weekly
Wages & Salaries (self)
_________

Wages & Salaries (partner) _________

Tips, Commissions, Overtime_________

Social Security Disability
_________

Social Security Retirement/
pensions
_________

Supplementary Security
Income
_________

TANF
_________

Unemployment
Compensation
_________

Worker’s Disability
Compensation
_________

Veterans’ Benefits
_________

Child or Spousal Support
_________


Biweekly Monthly









Other






































When it doesn’t come, what do you do? How do you manage?
Children’s wages
Food Stamps
Regular gifts from family/
friends
Others

_________
_________













_________
_________













203

2. Did you receive assistance from any of the following sources over the past year? [TRY
TO RECORD THE CASH VALUE IF POSSIBLE.]
Amount
WIC
__________ What do you get from WIC?
School Lunch/Breakfast Program
__________ Do your children eat the food?
Yes  No 
Earned Income Tax Credit
__________ What did you do with the money?
Childcare Assistance
__________
Housing Assistance
__________
Energy/fuel Assistance
__________
Transportation Assistance
__________
Education Grants or Loans
__________
Medicaid
__________
Diversionary Assistance
{IF APPLICABLE}
__________
Other [describe]______________ __________
3. Housing is usually the largest expense for families. Tell me about how much you pay per
month and what utilities, if any, are included. About how much do you pay each month
for the utilities that are not included in your rent? (PROBE to fill in chart)
Included in Rent
Pays Amount
Electricity


how much per month?______________
Gas/Oil/Wood/Coal 

how much per month?______________
Cable TV


how much per month?______________
Water


how much per month?______________
Garbage


how much per month?______________
This year energy prices have gone up. Has anything happened to you over the past few
months that has changed your housing costs? (PROBE:
Rent gone up? Utilities shut
off?) What did you do?
(PROBE IF PAYS UTILITIES) In the last year, did you ever have a difficult time
paying for the utilities? Yes  No 
[IF YES] What did you do? Was anything disconnected? Yes  No 
[IF YES] What did you do to get it turned on again?
Who helped?

4. Tell me about telephone service you have. About how much do you pay each month?
____________________
What services does this include? (PROBE: Internet connection, long distance, cell
phone, pager?) Have you had a problem paying for phone service in the last year?
Yes  No 

204

5. In the past year, have you had a problem paying for any of the following?
[FOR EACH YES] What have you done when this happened?
Food
Clothing
Medical care
Dental care
Medicines
Credit payments
Personal care items
Diapers
School fees or
expenses
Rent or house
payment
Anything else

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 
No 
No 

Yes 

No 

Yes 
Yes 

No 
No 

6. [OPTIONAL] What other monthly bills do you have? (PROMPT: rent-to-own?) How
much do you normally spend on these? Have you ever had trouble paying any of them?
Yes  No  [IF YES] What did you do?
7. Since we last talked, have you, or any members of your household, been close to going
hungry or ever gone hungry?
Yes  No  [IF YES] Tell me how this happened? What led to your being hungry?
8. Tell me about any strategies you have to help make the food last until the end of the
month. (PROMPT: Do you or your children ever eat at a family member’s or friend’s
house? Yes  No  [IF YES] Tell me about this.) (PROBE: How often does that
happen? Do you ever cook together with some other family to make enough for both
families? Yes  No 
(PROMPT: Have you gotten food from a food bank or soup kitchen during the last year?
Yes  No  [IF YES] Tell me about this. How useful was the kinds of food you got?)
9. [ADMINISTER FOOD SECURITY MODULE]
10. When people are having a hard time making ends meet, sometimes they will work for
cash by doing different kinds of odd jobs. Have you ever done anything like that?
Yes 
No 
(PROBE: Cleaned homes? Collected bottles/cans? Mowed lawns? Shoveled snow?)
[IF APPROPRIATE] Has your partner ever worked for cash?
Yes  No 

205

[IF YES] What did you do? How long? Have you done this in the last year?
Yes  No 
How much did you earn? _________ Did you like doing that work?
[IF NO] Do you know other people who do this? What do you think about it?
11. Compared with last year, would you say that your family’s economic situation has...
[CIRCLE NUMBER OF RESPONSE]
5 Improved a lot
4 Improved a little
3 Remained the same
2 Gone down a little
1 Gone down a lot
12. To what extent to do you think your income is enough for you to live on?
[CIRCLE NUMBER OF RESPONSE]
1 Not at all adequate
2 Can meet necessities only
3 Can afford some of the things we want but not all we want
4 Can afford about everything we want
5 Can afford about everything we want and still save money
13. During the last year, did you ever borrow money from a relative or friend?
Yes  No 
[IF YES] Why did you borrow it? How much did you borrow? ___________
Have you been able to pay it back? Yes  No 
[IF YES, PAID BACK] How were you able to do that?
[IF NOT PAID BACK] Has anything happened because you have not
been able to pay it back?
Yes  No 
14. If you got $20 tomorrow, what would you do with it?
15. If you got $200 tomorrow, what would you do with it?
16. What if your child needed a new pair of shoes, how would you get them for him or her?
17. Birthdays are often times for celebration. Tell me about how you celebrate your child’s /
206

children’s birthday(s). (PROBE: How much would you usually spend on a gift?)
18. When you think about your bills and the things you need to buy, how do you decide
which comes first if you don’t have the money for them all?
19. What are your favorite money-stretching techniques?

20. How has the health of your family been this year? Has the health of any family member
changed? How? (PROBE: Has a health problem affected your family life at all? How?)
21. ADMINISTER CHILD HEALTH SURVEY & ADULT HEALTH SURVEY.]

PARENTING
1. [IF LIVING WITH PARTNER/SPOUSE] What sort of parenting tasks do you typically
do? And what parenting tasks does your partner/boyfriend/spouse typically do?
2. Do you (and your partner/boyfriend/spouse IF APPLICABLE) get help or advice in
parenting from anyone else? What sort of help do they provide? How do you feel about
this help?
3. [IF RESPONDENT IS NOT LIVING WITH FATHER OF CHILD/REN] During the
past 12 months, how often did your child(ren) see their father(s)? Why? [MAKE SURE
THAT QUESTION IS ANSWERED FOR EACH NON-CUSTODIAL FATHER.]
Overall, what is your relationship like with _____________________’s {INSERT
NAME OF CHILD/CHILDREN} father?
Why do you say that?
Do you think that ____________’s {INSERT NAME OF CHILD/CHILDREN} father
wants a close relationship with his child?
What makes you say that? [ASK FOR EACH FATHER IF MORE THAN ONE.]

207

Do you ever have conflicts with _______’s {INSERT NAME OF CHILD/CHILDREN}
father about the child? Yes  No 
[IF YES] What are the conflicts about? (PROBE to fill in chart)
Custody
Yes 
No 
Child support
Yes 
No 
How child is being raised
Yes 
No 
Visits
Yes 
No 
Other
Yes 
No 
How do these conflicts get resolved?
4. [OPTIONAL] What is your number one wish for your child/ren? Why do you feel this
way? Has this changed over the last few months? Yes  No 
[IF YES] Why?
5. [ADMINISTER PARENTING LADDER.]
6. About how you responded to the last question on the Parenting Ladder, why do you feel
that way?

FAMILY WELL-BEING
{USE THE INFORMATION FROM WAVE 1 TO CONSTRUCT THE NEXT QUESTION.}
1. Last year, you said that the thing that you were looking forward to the most
was____________________.
How is that going? {OR WHATEVER THE APPROPRIATE FOLLOW-UP
QUESTION(S) MAY BE.}

{IF THERE IS SOMETHING ELSE FROM WAVE 1 THAT YOU WISH TO FOLLOW UP
ON WITH THE RESPONDENT, USE THE NEXT QUESTION AS A GUIDE. OTHERWISE
OMIT.}
2. Last year you mentioned _________________ (or you were _______). Is the situation
still the same? Have things changed? Gotten better? Gotten worse? {OR WHATEVER
THE APPROPRIATE FOLLOW-UP QUESTION(S) MAY BE.}

208

3. A. [OPTIONAL] Would you describe yourself as a person with religious or spiritual
beliefs? Yes  No 
[IF YES] Does this play a role in your everyday life? Yes  No 
How so?
B. {ALTERNATIVE WORDING} What do you rely on when times are difficult?
Religion? Family? Friends? How does this/do they help you?
4. Tell me about a typical day. (PROBE: What time do you get up? When do your children
get up? What happens next? And then? [THE GOAL HERE IS TO GET A PICTURE
OF A TYPICAL WEEKDAY FOR THE FAMILY.]
5. What sorts of things do you do for fun? [PROBE: Do you have any hobbies?]
6. What things about your family make you proud and happy right now?
7. What are the biggest challenges for your family as a whole?
8. How are things going for your family right now? Tell me about that. How are things
going for you personally?
9. [IF HAS PARTNER] How are things between you and your partner? Tell me about that.
10. Is there any one who is making things harder for your family right now? Tell me about
that.
11. Overall, how satisfied are you with your life right now?
[CIRCLE NUMBER OF RESPONSE]
1 Very dissatisfied
2 Dissatisfied
3 Mixed feelings
4 Satisfied
5 Very satisfied
Why do you feel that way?

209

12. [ADMINISTER FEELINGS ABOUT HOW THINGS ARE GOING MEASURE.]
SOCIAL SUPPORT
1. Have you made any new friends over the past year? What has made that possible?
2. Are you able to get together with friends? What kinds of things do you do? How often?
3. Are there any old friends that you have lost contact with over the last year? Tell me a
little about that.
SUMMARY
1. What is the most important thing that happened to your family in the past year?
Did something good happen to you or one of your children? Did something not
so good happen to you or one of your children?
2. Thinking ahead to the coming year, what are you looking forward to? What worries you?
What do you think things will be like for your family next year at this time?
3. What do you think things will be like for your family in three years? Why do you think
this?
4. Is there anything else you think we should know about how your family is doing right
now? Is there anything we have missed?
[PLEASE MAKE SURE THAT THE CONTACT PERSON IS STILL THE SAME, AND THAT
PERSON’S INFORMATION IS STILL THE SAME.
5. The last time we talked, you said that ___________ would know how to find you if we
were unable to contact you. Has this changed?
Contact Information from Wave I:
PLEASE MAKE ANY CHANGES OR WRITE NEW CONTACT INFORMATION BELOW
BEFORE ENDING THE INTERVIEW:

This is the end of the interview. Thank you so much.
210

There are many community services that families need to know how to access. The services
needed are different for each family. If you needed it, would you know where to go to:
Table B.1. Knowledge Of Community Resources
Service

Yes

3.

Get help on heating bills

4.

Apply for subsidized housing

3.

Find temporary housing

4.

Apply for Medicaid

5.

Find help for a drug or alcohol problem

6.

Find help for a domestic violence problem

7.

Get your child immunized

8.

Find a family doctor

9.

Find dental care

10

Find a mental health counselor

11.

Find family planning services

12.

Apply for welfare

13.

Get legal assistance

14.

Apply for food stamps

15.

Apply for WIC

16.

Locate job training

17.

Find transportation choices

18.

Find child care

19.

Apply for a child care subsidy

20.

Find help for a family member with disabilities

21.

Find low-cost clothing for your family

23

Find Cooperative Extension Activities (EFNEP,

211

No

Table B. 2. Life Skills Assessment
Do you have:
1.

A driver's license

2.

Car insurance

3.

Car registration

4.

Heath insurance

5.

A checking account

6.

A good credit record

7.

Yes

A local library card

Do you know how to:
8

Manage your bills

9

Write a personal check

10

Make a family budget

11.

Stretch your groceries to the end of the month

12.

Register to vote

13.

Apply for a credit card

14.

Prepare a well-balanced meal for your family

15.

Get telephone service

16.

Work with your landlord to improve housing

17.

Register a consumer complaint

18.

Talk to your child's teacher

19.

Fill out forms to apply for services

20.

Apply for a job

21.

Write a resume

22.

Dress for a job

23.

Fill out your own income tax forms

24.

Join a local club or organization

25.

Create a personal support system

212

No

For each of the following statements, check the box that best describes HOW OFTEN YOU
HAVE FELT THIS WAY DURING THE PAST WEEK.
Table B. 3. Feelings About How Things Are Going
Rarely or
none of
the time
1. I was bothered by things that
don’t usually bother me
2. I did not feel like eating; my
appetite was poor
3. I felt that I could not shake the
blues even with help from my family
and friends
4. I felt that I was just as good as
other people
5. I had trouble keeping my mind on
what I was doing
6. I felt depressed
7. I felt that everything I did was an
effort
8. I felt hopeful about the future
9. I thought my life had been a
failure
10. I felt fearful
11. My sleep was restless
12. I was happy
13. I talked less than usual
14. I felt lonely
15. People were unfriendly
16. I enjoyed life
17. I had crying spells
18. I felt sad
19. I felt that people disliked me
20. I could not “get going”

A little
of the
time

A moderate
amount of
time

Most or
all of
the time

















































































































213

Figure B. 1. The Parenting Ladder
6 High
5
4
3
2
1
0 Low

Where would you put yourself on the Parenting Ladder in terms of:
Your knowledge of how children grow and develop?

_________

Your confidence that you know what is right for your child?_________
Your ability to create a safe home for your child?

_________

Your success in teaching your child how to behave?

_________

Your skill at finding fun activities that interest your child? _________
The amount of stress in your life right now?

_________

Your ability to cope with the stress in your life?

_________

Parenting is often smoother when others are there to help. Where would
you put yourself on the Parenting Ladder in terms of:
Other parents for you to talk to?

_________

Someone to help you in an emergency?

_________

Someone to offer helpful advice or moral support?
Someone for you to relax with?

____
_________

Professional people to talk to when you have a question
about your child?

_________

Your overall satisfaction with the amount of support
in your life?

_________

214

ADULT HEALTH SURVEY
Do you and/or your partner
have medical insurance?
You Yes_____ No_____
Partner Yes_____ No_____
If yes, what kind?

Private/HMO

Medicaid/MA

State Health Plan

Other (Explain)
_____________________
Do you and/or your partner
have any type of dental
insurance?
You Yes_____ No_____
Partner Yes_____ No_____
If yes, what kind?

Private

Medicaid/MA

Other (explain)

About how many times in
the past year have you
been to a doctor or
other health care
provider?
_____________________
_____
Your
partner?______________
____
If none, when was the last
time you visited a doctor
or health care provider?
_____________________
Your
partner?______________
About how many times in
the past year have you
visited a
dentist?_______________
Your
partner?______________
If none, when was the last
time you did visit a
dentist?

Your
partner?______________

Have you or your
partner had any
injuries or serious
illnesses in the past
year?
You Yes _____
No _____
Partner Yes _____
No _____
If yes, please explain
_________________
_________________
_________________
About how many
times in the past year
have you missed
work due to an
illness/injury?
_______________
Your
partner?_________
Have you been
pregnant in the past
three years
Yes_____ No_____
If yes: How many
times__________
Are you and your
partner able to have
more children?
Yes_____ No_____
If so, do you
currently use birth
control?
Yes_____ No_____

215

In the past three years, have you or your partner experienced any of the following
health problems?
You
Heart Problems

High Blood Pressure 
Diabetes

Cancer
Digestive
Problems
Liver Problems
Seizure Disorder
Depression/Anxiety

Partner


















Joint Problems
Chronic Pain
Eating Disorder/
Obesity
Skin Problems
Permanent Disability
Sexually Transmitted
Disease
Reproductive
Problems
Bladder Infections
Drug Problem
Alcohol Problem
Tobacco Use

Anger Management 

Hepatitis


Allergies


Asthma


Frequent colds/
flu/sinus


Anemia
Thyroid Problems


Emotional, physical,
Kidney Problems


or sexual abuse
Fatigue


Migraines/Headaches
Eye or vision
problems


Learning Disabilities
Back Problems


Arthritis
Other (specify)____________________________________

216

You



Partner











































First name of: Child 1:________________ Child 2: ________________
Child 3: ________________
CHILD HEALTH SURVEY
Does C1 have medical
insurance?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
___________________
__________
C2:  Yes  No If yes,
what kind?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
___________________
__________
C3:  Yes  No If yes,
what kind?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
___________________
__________
About how many times
in the past year has your
child been to a doctor or
other health care
provider?
C1 _______ C2 ______
C3 _______

Does C1 have any type of
dental insurance?  Yes 
No If yes, what kind?

Private

Medicaid/MA

Other (Explain):

If none, when was the
last time your child
visited a doctor or health
care provider?
C1 ______ C2 _____
C3 ______

C1 ________ C2 _______
C3 ______

C2:  Yes  No If yes, what
kind?

Private

Medicaid/MA

Other (Explain):
__________
C3:  Yes  No If yes, what
kind?

Private

Medicaid/MA

Other (Explain):

About how many times in
the past year has your child
visited a dentist?
C1 _______ C2 _______ C3
______
If none, when was the last
time your child did visit a
dentist?

217

Has your child had
any injuries or
serious illnesses in
the past year?
C1:  Yes No
C2:  Yes No
C3:  Yes No
If yes, please
explain___________
_________________
_________________
_________________
_________________
_________________
_____________
About how many
times in the past year
has your child missed
school due to an
illness/injury?
C1: _________
C2: _________
C3: _________

In the past three years, has your child experienced any of the following health problems?
C1
Allergies

Anemia

Asthma

Cancer

Chronic Pain

Learning Disability 
Depression/Anxiety 
Anger Management 
Diabetes

Digestive Problems 
Drug Problem

Alcohol Problem

Ear Infections

Eating Disorder/
Obesity

Eye or vision

Fatigue

Frequent colds/flu/
sinus 
Hepatitis

Seizure Disorders

Skin Problems


C2














C3



























C1








Head Lice
Behavior Problems
Conjunctivitis
(pink eye)

ADD/ADHD

Fetal Alcohol Effects/
Syndrome

Fetal Drug Effects

Broken Bones

Sexually Transmitted
Disease

Skeletal Problems

Tobacco Use

Migraines/Headaches 
Permanent Disability 
Other (specify)

218

C2



C3





























FOOD SECURITY MODULE
These next questions ask about the food eaten in your household in the last 12 months, since
(current month) of last year, and whether you were able to afford the food you need.
1. Which of these statements bests describes the food eaten in your household in the last 12
months:
[1] Enough of the kinds of food we want to eat (SKIP 1a and 1b)
[2] Enough but not always the kinds of foods we want (SKIP 1a)
[3] Sometimes not enough to eat (SKIP 1b)
[4] Often not enough to eat (SKIP 1b)
[ ] DK or Refused (SKIP 1a and 1b)
1a.

[IF OPTION 3 OR 4 SELECTED, ASK] Here are some of the reasons why people don’t
always have enough to eat. For each one, please tell me if that is a reason why YOU
don’t always have enough to eat. [READ LIST. MARK ALL THAT APPLY.]
YES







1b.

NO







DK






problems

Not enough money for food
Not enough time for shopping or cooking
Too hard to get to the store
On a diet
No working stove available
Not able to cook because of health

[IF OPTION 2 SELECTED, ASK] Here are some reasons why people don’t always have
the quality or variety of food they want. For each one, please tell me if that is a reason
why YOU don’t always have the kinds of food you want to eat. [READ LIST. MARK
ALL THAT APPLY.]
YES






NO






DK






Not enough money for food
Kinds of food we want not available
Not enough time for shopping or cooking
Too hard to get to the store
On a special diet

219

2. Now I’m going to read you several statements that people have made about their food
situation. For these statements, please tell me whether the statement was often true,
sometimes true, or never true for your household in the last 12 months, that is, since last
(name of current month).
The first statement is “We worried whether our food would run out before we got money
to buy more.” Was that often true, sometimes true, or never true for your household in
the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
3. “The food that we bought just didn’t last, and we didn’t have money to get more.” Was that
often, sometimes or never true for your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
4.

“We couldn’t afford to eat balanced meals.” Was that often, sometimes or never true for
your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused

5. “(I/We) relied on only a few kinds of low-cost food to feed (my/our) child/ren because (I
was/we were) running out of money to buy food.” Was that often, sometimes or never true
for your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
6. “(I/We) couldn’t feed (my/our) child/ren a balanced meal, because I couldn’t afford that.”
Was that often, sometimes or never true for your household in the last 12 months?
 Often True
 Sometimes True
 Never True
 DK or Refused
If answer “often true” or “sometimes true” to any one of Questions 2-6, or response [3] or [4] to
Question 1, then ask questions 7-16, otherwise stop here.

220

7. “(My/Our child was/The children were) not eating enough because (I/we) just couldn’t afford
enough food.” Was that often, sometimes or never true for your household in the last 12
months?
 Often True
 Sometimes True
 Never True
 DK or Refused
8. In the last 12 months, since last (name of current month), did you (or other adults in your
household) ever cut the size of your meals or skip meals because there wasn’t enough money
for food?
 Yes
 No (Skip 8a)
 DK (Skip 8a)
8a. [IF YES ABOVE, ASK] How often did this happen—almost every month, some months but
not every month, or in only 1 or 2 months?
 Almost every month
 Some months, but not every month
 Only one or 2 months
 DK
9. In the last 12 months, did you ever eat less than you felt you should because there wasn’t
enough money to buy food?
 Yes
 No
 DK
10. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford
enough food?
 Yes
 No
 DK
11. In the last 12 months, did you lose weight because you didn’t have enough money for food?
 Yes
 No
 DK
If any answer to Question 7-11 is affirmative, continue, otherwise stop here.
12. In the last 12 months did (you/you or other adults in your household) ever not eat for a
whole day because there wasn’t enough money for food?
 Yes
 No (Skip 12a)
221

 DK (Skip 12a)
12a. [IF YES TO 12, ASK] How often did this happen—almost every month, some months, but
not every month, or in only 1 or 2 months?
 Almost every month
 Some months, but not every month
 Only one or 2 months
 DK
13. The next questions are about children living in the household who are under 18 years old. In
the last 12 months, since (current month) of last year, did you ever cut the size of (your
child’s/any of the children’s) meals because there wasn’t enough money for food?
 Yes
 No
 DK
14. In the last 12 months, did (CHILD’S NAME/any of the children) ever skip meals because
there wasn’t enough money for food?
 Yes
 No (skip 14a)
 DK (skip 14a)
14a. [IF YES ABOVE, ASK] How often did this happen—almost every month, some months but
not every month, or in only 1 or 2 months?
 Almost every month
 Some months, but not every month
 Only one or 2 months
 DK
15. In the last 12 months, (was your child/were the children) ever hungry but you just couldn’t
afford more food?
 Yes
 No
 DK
16. In the last 12 months, did (your child/any of the children) ever not eat for a whole day
because there wasn’t enough money for food?
 Yes
 No
 DK

222

APPENDIX C

Wave Three Protocol

223

Interviewer__________________ ID:__________________ Date: _____________ W1
Date__________ W2 Date____________
I want to thank you for agreeing to be interviewed again this year. Just like before, we are
interested in hearing what life is like for you and your family. I want to remind you that the
interview is voluntary. If you do not want to answer a question, you don’t have to. All
information that you give us will be kept confidential.
Before we begin, I want to make clear that the time period we want to gather information about
is between the date of our last interview, _________ {give date of wave 2 interview}, and today.
I will keep reminding us both of this as I ask you the questions.
[DO NOT PROCEED UNLESS PARTICIPANT HAS SIGNED THE INFORMED CONSENT
FORM.]
Notes from
previous interview
CURRENT HOUSEHOLD COMPOSITION
Partner/Spouse:
Mother’s 1st Name_______________________
We’d like to catch up on any changes in your life and in your family
since our last interview on _______.
1. Last time, you said that [GIVE NAMES] ___________________
were living in your household.
Have there been any changes since our last interview?
 No → [GO TO QUESTION #2]
 Yes →

Child(ren):
________________
________________
________________
________________
________________
________________
________________
________________
____

1A) What has changed?
[FILL OUT CHART BELOW FOR NEW CHILD/PARTNER]
1B) [IF CHILD MOVED OUT] When? Why? Where is child living now?
1C) [IF PARTNER MOVED OUT]

When? Why?

1D) [IF NEW PARTNER MOVED IN] How long has your new partner lived here?
1E) Any other changes? Are there any other new members of your household?

224

(FILL IN CHART FOR NEW CHILDREN/PARTNER)
New Child
(first name)

Sex

Relation
Contact w/ Receives
Partner/
bio parent child support
Spouse
(Y, N)
(Y, N)
1. _____________ _____ ________ ___________ __________ ________ __________
2. _____________ _____ ________ ___________ __________ ________ __________
3. _____________ _____ ________ ___________ __________ ________ __________
New Partner

DOB

DOB

Relation
Mother

Ethnicity

4. __________________ ____________ ________
[IF APPLICABLE] Does your partner have any children not currently living with you?
___________________________________
* Key to codes
S = Single
M = Married

**Key to Codes
W = Non-Hispanic White
H = Hispanic/Latino

*** Key to codes
A = Adopted
SC = Stepchild

LWP = Living /partner
D = Divorced
SEP = Separated

AA = African American
N = Native American
A = Asian
M = Multi-racial
O = Other

B = Biologicalchild
F = Foster child
NR = Not related
O = Other

2. Last year you told us you were _______________________. {married, separated, divorced,
single, living with _______}.
Has that changed?
 Yes →
2A) What has changed? ______________ (see chart on previous page for
 No
appropriate code)

225

FAMILY WELL-BEING
1. What is the most important thing that happened to your family
since our last interview?
Did something good happen to your family? Did something not so
good happen to your family?

Family Well-Being
notes from previous
interviews:

2. How are things going for your family right now? Tell me about
that.
3. [IF HAS PARTNER] How are things between you and your
partner? Tell me about that.
4. Relationships with family members can change over time; get
better, get worse, or just be different.
Since our last interview, what changes have there been in your
relationships with your
parents, brothers and sisters, or other relatives?
SOCIAL SUPPORT
1. How often during the last month did friends give you practical help?
 Often
 Sometimes
 Rarely
 Never
2. [IF APPROPRIATE] What types of things have friends done for you and your family?
3. How often during the last month did relatives (excluding partner) give you practical help?
 Often
 Sometimes
 Rarely
 Never
4. [IF APPROPRIATE] What types of things have relatives done for you and your family?
5. How many people (excluding partner) could you call on for help if you were having trouble?
 No one
 1 or 2 people
 3-5 people
 6-9 people
 10 or more

226

LIVING IN THE COMMUNITY
1.
Have you moved since our last interview?
 No → [GO TO QUESTION #9]
 Yes →
1A) How many different places have you lived? ______

2.
Is your current home now adequate for your needs?
 No →
 Yes
2A) What makes your current home inadequate?

3. [IF LIVING IN A DIFFERENT COMMUNITY FROM PREVIOUS INTERVIEW]
There are many community services that families need to know how to access, and what each
family needs may be very different.
I would like to know about the kinds of community services you know about.
[ADMINISTER KNOWLEDGE OF COMMUNITY RESOURCES MEASURE]
4. Were you without you own home (homeless) at any point since our last interview?
 Yes
 No
[FOR ALL PARTICIPANTS]
5. Do you feel safe where you live? Yes  No  Why or why not?
TRANSPORTATION
1. [IF FAMILY OWNED VEHICLE AT LAST INTERVIEW BEGIN HERE]
At our last interview, you said … (reliable/unreliable vehicle?)
Has that changed?
Transportation notes from
previous interviews:

227

2. Since our last interview, have you had any problems with your vehicle(s)?

 Yes →

 No 

2A) Tell me about what happened.
What did you do?
2B) Do you still own a vehicle?
 Yes  [GO TO
QUESTION #5]
 No  [GO TO
QUESTION #4]
2C) [GO TO QUESTION #5]

3. [IF NO VEHICLE AT LAST INTERVIEW BEGIN HERE]
Last time we talked you said…
Since our last interview, have you gotten a vehicle?
3A) Do you still depend
on …?
[GO TO QUESTION #4]

 No 

 Yes 

3B) [GO TO QUESTION
#5]

4. [IF FAMILY DOES NOT CURRENTLY OWN CAR] How does your family’s not owning a
car affect how you get to appointments (medical, welfare, etc.), work or training programs? [GO
TO QUESTION #6]
5. [IF FAMILY CURRENTLY OWNS CAR] If your car breaks down or is not available to you,
how do you get to work, appointments, and the grocery store, etc.?
6. How long does it take you …
a.
… to get to work?
b.
… to get to medical appointments?
c.
… to get to welfare appointments?
7.

Have you ever had to miss work or a training program because of a transportation problem?
 Yes →
 No

7A) How did your supervisor react?

228

EMPLOYMENT/CURRENT WORK
A. PARTICIPANT’S EMPLOYMENT/CURRENT WORK
1. Since our last interview, have you gotten any further education or training?
 Yes →
1A) Tell me about that. What kind was it and where did
 No
you do it?
1B) How did you pay for it?
[IF RESPONDENT WAS WORKING AT WAVE 2, BEGIN HERE]
[IF RESPONDENT WAS NOT WORKING AT WAVE 2, GO TO QUESTION #7]

Participant employment information from wave 2:
Amount
Wage/Salary Started

Date
Hours/wk

Weeks/yr

of Raise

Job 1____________

__________

______

________

_______ ______

Job 2____________

__________

______

________

_______ ______

JOB 1
Health insurance
Yes  No  DK 
for yourself
Health insurance
Yes  No  DK 
for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 

DK 
DK 
DK 
DK 

JOB2
Health insurance for Yes  No  DK 
yourself
Health insurance
Yes  No  DK 
for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 

DK 
DK 
DK 
DK 

2. At our last interview you said you were working at ___________. Are you still working
there?
 No → [GO TO QUESTION #5]
 Yes

229

3.

How is your job/work going for you? Has anything changed about your job? Such as….

Different responsibilities
Yes  No 
Different hours
Yes  No 
Have you had a raise, promotion, or received new benefits?
 Yes →
3A) When? ________
How much? ___________What kind of
 No
benefits?________________
3B) Has the raise, promotion, or new benefits changed your family
life in any way? (such as new hours or longer hours)

4. Do you have any additional jobs?
 Yes →
4A) Why did you get an additional job?
4B) Tell me about your other job(s).
4C) [FILL OUT JOB 2 ON CHART BELOW [Question #8]]
4D) [GO TO B. Partner’s Employment/Current
Work]

 No →

4E) [GO TO B. Partner’s Employment/Current Work]

5. What happened with that job? (PROBE: Why did you leave that job?)
6. Are you currently working?
 Yes  [FILL OUT CHART BELOW [Question #8]]
 No 
6A) Have you looked for work?
 YesHow has that gone?
Have you held any other jobs since our last interview?
Tell me about that/them.
[GO TO B. Partner’s Employment/Current Work]
 NoFor what reasons are you not looking for work?
Have you held any other jobs since our last interview?
Tell me about that/them.
[GO TO B. Partner’s Employment/Current Work]

230

[IF RESPONDENT WAS NOT WORKING LAST YEAR, BEGIN HERE]
7. At our last interview, you said you were not working. Are you working now?
 Yes  [FILL OUT CHART BELOW [Question #8]]
 No 
7A) Have you looked for work?
 YesHow has that gone?
Have you held any jobs since our last interview?
Tell me about that/them.
[GO TO B. Partner’s Employment/Current Work]
 NoFor what reasons are you not looking for work?
Have you held any jobs since our last interview?
Tell me about that/them.
[GO TO B. Partner’s Employment/Current Work]
8. [IF YES, PARTICIPANT IS WORKING AT A NEW JOB] Tell me about the job(s) you have
now. How did you find this job? Did you know somebody who already worked there? (PROBE
to fill in chart: Where are you working now? What is it that you do? Are you working full-time
or part-time?)

Participant employment

Date
Wage/Salary Started

Hours/wk Weeks/yr

Amount
Raise

Job 1 ____________________

__________

______

________ _______

______

Job 2 ____________________

__________

______

________ _______ ______

(PROBE to fill in chart: Do you get any benefits with this new job(s)?)
JOB 2 information
Health insurance for yourself
Health insurance for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

231

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

9. [IF WORKING AT WAVE 1 OR 2] How does this job compare to your old job? Why do
you say that? Has the new job made any difference in your family life?
(PROBE: wages, hours, etc.)
B. PARTNER’S EMPLOYMENT/CURRENT WORK
[IF RESPONDENT HAS SAME PARTNER WHO WAS WORKING AT WAVE 2, BEGIN
HERE]
[IF RESPONDENT HAS SAME PARTNER WHO WAS NOT WORKING AT WAVE 2, GO TO
QUESTION #6]
[IF NEW PARTNER, GO TO QUESTION #9]

Participant employment

Date
Wage/Salary Started

Amount
Hours/wk Weeks/yr Raise

Job 1 ____________________

__________

______

________ _______

Job 2 ____________________

__________

______

________ _______ ______

______

(PROBE to fill in chart: Do you get any benefits with this new job(s)?)
JOB 2 information
Health insurance for yourself
Health insurance for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

10. Last time we talked, you said ___________________ was working at _______________.
Is he/she still working there?
 No → [GO TO QUESTION #4]
 Yes
11. Has anything changed about his/her job? Such as….
Different responsibilities
Yes  No 
Different hours
Yes  No 
Has he/she had a raise, promotion, or received new benefits?
 Yes →
11A) When? ________
How much? ___________What kind of
 No
benefits?____________
11B) Has the promotion, raise, or new benefits changed your
family life in any way? (such as new hours or longer hours)
232

12. Does he/she have any additional jobs?
 Yes →

 No →
13.
14.

12A) Why did he/she get an additional job?
12B) Tell me about his/her other job(s).
12C) [FILL OUT JOB 2 ON CHART BELOW [Question #7]]
12D) [GO TO C. Other Employment]

/

12E) [GO TO C. Other Employment]

Can you share with me what happened and why he/she is not working at the same job?
(PROBE: Why did he/she leave the other job?)
Is he/she currently working?
 Yes → [FILL OUT CHART BELOW [Question #7]]
 No →
5A) Has he/she looked for work?
 Yes → How has that gone?
Has he/she held any other jobs since our last interview?
Tell me about that/them?
[GO TO C. Other Employment]
 No → For what reasons is he/she not looking for work?
Has he/she held any other jobs since our last interview?
Tell me about that/them?
[GO TO C. Other Employment]

[IF RESPONDENT HAS SAME PARTNER WHO WAS NOT WORKING AT WAVE 2, BEGIN
HERE]
15. At the last interview you said _________________ was not working. Is he/she working
now?
 Yes  [FILL OUT CHART BELOW [Question #7]]
 No 
15A) Has he/she looked for work?
 Yes How has that gone?
Has he/she held any jobs since our last interview?
Tell me about that/them?
[GO TO C. Other Employment]
 No For what reasons has he/she chosen not to look for work?
Has he/she held any jobs since our last interview?
Tell me about that/them?
[GO TO C. Other Employment]
233

16. [IF YES, SAME PARTNER WORKING AT A NEW JOB] Tell me about his/her job(s).
(PROBE: How did he/she find out about the job? Did he/she know someone already working
there? Where is he/she working now? What is it that he/she does? Is he/she working full-time or
part-time? (PROBE to fill in chart.)

Date
Wage/Salary Started

Partner employment

Hours/wk Weeks/yr

Amount
Raise
______

Job 1 ____________________

__________

______

________ _______

Job 2 ____________________

__________

______

________ _______ ______

(PROBE to fill in chart: Do you get any benefits with this new job(s)?)
JOB 2 information
Health insurance for yourself
Health insurance for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

17. [IF WORKING AT WAVE 1 OR 2] How does this job compare to his/her old job? Why do
you say that?
[IF RESPONDENT HAS A NEW PARTNER, BEGIN HERE]
18. Is your partner employed?
 Yes  [FILL OUT CHART ON NEXT PAGE [Question #10]]
 No 
18A) Has he/she looked for work?

 Yes How has that gone?
Has he/she held any jobs since you’ve lived together?
Tell me about that/them?
[GO TO C. Other Employment]
 No For what reasons is he/she not looking for work?
Has he/she held ant jobs since you’ve lived together?
Tell me about that/them?
[GO TO C. Other Employment]

234

19. [IF YES, NEW PARTNER IS WORKING] Tell me about his/her current job(s).
(PROBE to fill in chart: Where is he/she working now? What is it that he/she does? Is he/she
working full-time or part-time? )

New Partner employment

Date
Wage/Salary Started

Amount
Hours/wk Weeks/yr Raise

Job 1 ____________________

__________

______

________ _______

Job 2 ____________________

__________

______

________ _______ ______

______

(PROBE to fill in chart: Do you get any benefits with this new job(s)?)
JOB 2 information
Health insurance for yourself
Health insurance for children
Sick leave
Vacation
Overtime
Retirement plan

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

Yes 
Yes 
Yes 
Yes 
Yes 
Yes 

No 
No 
No 
No 
No 
No 

DK 
DK 
DK 
DK 
DK 
DK 

C. OTHER EMPLOYMENT
1. Does anyone else in the household have a job? (PROBE: Do any children have a job?)
 Yes 
1A) Tell me about
 No
that.
2. [IF RESPONDENT IS CURRENTLY WORKING] Is there anything in your life that makes
it more difficult for you to hold down a job (or participate in a training program)? What about
… (PROBE to fill in chart)
Childcare
No 
Transportation No 
Health issues No 
Family issues No 
Your partner No 

Yes
[FOR ALL “YES”
Yes
RESPONSES]
Yes
Tell me about that.
Yes
Yes

235

3. [IF PARTICIPANT IS NOT CURRENTLY WORKING] Since you are not currently
working outside the home, is there anything in your life that makes it more difficult for you to
work or participate in a training program? What about …(PROBE to fill in chart)
Childcare
No 
Transportation No 
Health issues No 
Family issues No 
Your partner No 

Yes 
Yes
Yes
Yes
Yes

[FOR ALL “YES”

RESPONSES]
Tell me about that.

INCOME AND MAKING ENDS MEET
1. We would like to know about your family’s sources of income. Remember, all of this
information is completely confidential. From which of the following did you receive income this
year? (PROBE for changes in TANF, child and spousal support, food stamps, wages: Has that
been the same all year? Tell me about the change.)

Income

Amount
Wages & Salaries (self)
_________
Wages & Salaries (partner) _________
Tips, Commissions, Overtime_________
Social Security Disability
_________
Social Security Retirement/
Pensions
_________
Supplementary Security
Income (SSI)
_________
TANF
_________
Unemployment
Compensation
_________
Worker’s Disability
Compensation
_________
Veterans’ Benefits
_________
Child or Spousal Support
_________
Children’s wages
_________
Food Stamps
_________
Regular gifts from
family/friends
_________
Income Tax Refund
_________
Other, including odd jobs
_________

Weekly

236

Biweekly

Monthly

Other

2. Have you ever received TANF benefits?
 Yes →
 No
2A) How much time do you have on your TANF clock?
2B) Is the time limit a concern for you and your family? Why?

3. Did you receive assistance from any of the following sources since our last interview? If so,
how much?
[RECORD CASH VALUE]
Amount
__________

Assista

Weekly

Biweekly Monthly

Other

WIC
Yes  No 
School Lunch/
Breakfast Program Yes  No 
__________
Food Stamps
Yes  No 
__________
Earned Tax Credit
Yes  No 
__________
Childcare Assistance Yes  No 
__________
Housing Assistance Yes  No 
__________
(PROBE: Do you receive any help paying the rent/mortgage?)
Energy/fuel
Assistance
Yes  No 
_____
Transportation
Assistance
Yes  No 
__________
Education Grants
or Loans
Yes  No 
__________
Medicaid
Yes  No 
XXXXXXX
Diversionary
[IF APPLICABLE] Yes  No 
__________
Other
[describe]__________Yes  No 
__________

4. Housing is usually the largest expense for families.
Do you…
4A) What is your monthly mortgage bill? ___________________
OR

OR

4B) What is your monthly rental bill? _________________
4C) [IF TRAILER] What is your monthly lot rental bill? _____________

4D) Please describe.
4C) What is your monthly bill? ______________
237

5. Since our last interview, did you ever have a difficult time paying for your rent or mortgage?
 Yes
 No
 No; someone else paid
6. About how much do you pay each month for the utilities?
Included in Rent
Electricity
Yes 
Gas/Oil/Wood/
Coal
Yes 
Cable TV
Yes 
Water
Yes 
Garbage
Yes 

Pays

Amount

In winter?

No 

Yes  No 

how much per month?________

No 
No 
No 
No 

Yes 
Yes 
Yes 
Yes 

how much per month?_________
how much per month?_________
how much per month?_________
how much per month?_________

No 
No 
No 
No 

7. Since our last interview, did you ever have a difficult time paying for the utilities?
 Yes
 No
 No; someone else paid
8. Do you have telephone service?
 Yes →
1.
10A) About how much do you pay each month? ________________
 No
9. Have you had a problem paying for phone service since our last interview?
 Yes
 No
 No, have not had phone service during this time

238

10. Since our last interview, have you had a problem paying for any specific items?
Food
No  Yes 
[FOR ALL YES RESPONSES]
Clothing
No  Yes 
12A) What have you done when this happened?
Medical care
No  Yes 
Dental care
No  Yes 
Medicines
No  Yes 
Credit payments
No  Yes 
Personal care items No  Yes 
Diapers
No  Yes 
School fees or
expenses
No  Yes 
Property/school taxes No  Yes 
Childcare
No  Yes 
Car repair/
maintenance
No  Yes 
Anything else
No  Yes 
(For example: insurance, loan payments, etc )
11. When people are having a hard time making ends meet, sometimes they will work for cash
by doing different kinds of odd jobs. Since our last interview, have you done anything like that?
(PROBE: Cleaned homes? Collected bottles/cans? Mowed lawns? Shoveled snow?)
 Yes →
11A) What did you do? ______________
 No
11B) For how long? ______________
11C) How much did you earn? _________

12. [IF HAS PARTNER] Since our last interview, has your partner done anything like that?
 Yes →
12A) What did he/she do? _____________
 No
12B) For how long? _____________
12C) How much did he/she earn? _________

13. Compared with last year, would you say that your family’s financial situation has... [CIRCLE
NUMBER OF RESPONSE]
5 Improved a lot
4 Improved a little
3 Remained the same
2 Gone down a little
1 Gone down a lot
14. [RESTATE RESPONSE FROM QUESTION #19] What leads you to say that?
239

15. To what extent to do you think your income is enough for you to live on? [CIRCLE
NUMBER OF RESPONSE]
1 Not at all adequate
2 Can meet necessities only
3 Can afford some of the things we want but not all we want
4 Can afford about everything we want
5 Can afford about everything we want and still save money
16. [IF CHOOSES 2 OR 3 FROM QUESTION #21] When you think of necessities, what do
you think of?

LIFE SKILLS SECTION
1. In general, how often are you able to pay your bills?
 Always
 Sometimes
 Never
2. In general, how often are you able to stick to a family budget?
 Always
 Sometimes
 Never
3. In general, how often are you able to stretch your groceries to the end of the month?
 Always
 Sometimes
 Never
4. In general, how often are you able to prepare a well-balanced meal for your family?
 Always
 Sometimes
 Never

240

FOOD SECURITY
1. Since our last interview, have you or any members of your household, been close to going
hungry or ever gone hungry?
 Yes →
1A) Tell me how this happened. What led to your being hungry?
 No
2. Have you gotten food from a food bank or soup kitchen since our last interview?
 Yes →
2A) Tell me about this.
 No
2B) How often?
3. [ADMINISTER FOOD SECURITY MODULE]
HEALTH
A. ADULT HEALTH
1. At the previous interviews you mentioned that you… (describe health conditions from
previous interviews).
How has your health been since your last
Health Notes from Previous
interview?
Interviews
Participant:
2. Have there been any changes in your health?
3. Have you developed any new medical
conditions?
 Yes →
3A) Please explain.
 No
4. Since the last interview, have you had any injuries, surgeries, or
serious illnesses?
 Yes →
4A) Please explain.
 No
New Health Conditions
5. Since the last interview, have any of your health problems resolved?
Participant:
 Yes
 No

→

5A) Please explain.

6. Have you been pregnant (again) since the last interview?
 Yes →
6A) How many times?
 No

241

[FOR SAME PARTNER]
7. At the previous interviews you mentioned that your partner… (describe health conditions
from previous interviews).
How has your partner’s health been since the last
Health Notes from Previous
interview?
Interviews
8.
Have there been any changes in your partner’s
health?

Partner:

9.
Has your partner developed any new medical
conditions?
 Yes →
9A) Please explain.
 No
10. Since the last interview, has your partner had any
injuries, surgeries, or
serious illnesses?
 Yes →
10A) Please explain.
 No

New Health Conditions
Partner:

11. Since the last interview, have any of your partner’s
health problems resolved?
 Yes →
11A) Please explain.
 No

12. [FOR NEW PARTNER] We’d like to hear about
your partner’s health.→

12A) Administer Adult Health
Problems.

13. [ADMINISTER ADULT HEALTH SURVEY.]
14. [ADMINISTER SF-36 TO PARTICIPANT ONLY.]
Health Notes from Previous
Interviews
C1:
B. CHILD HEALTH

C2:

1.
At the previous interviews you mentioned that
_______(C1’s name) …
(describe health conditions from previous interviews).

C3:

How has ______’s (C1’s name) health been since the
last interview?

Etc:

242

C4:

2.

Have there been any changes in _______’s (C1’s name) health?

3. Has _______ (C1’s name) developed any new medical conditions?
 Yes
 No

→

3A) Please explain.

New Health Conditions:
C1:
C2:

C3:

C4:

C5:

C6 :

4. Since the last interview, has ________ (C1’s name) had any injuries, surgeries, or serious
illnesses?
 Yes →
 No

4A) Please explain.

5. Since the last interview, have any of _________ (C1’s name) health problems resolved?
 Yes →
5A) Please explain.
 No
6. [REPEAT FOR EACH CHILD WHO WAS LIVING IN HOUSEHOLD AT EITHER WAVE
1 OR WAVE 2]
7. [FOR EACH NEW CHILD LIVING IN HOUSEHOLD]
We’d like to hear about _______’s (child’s name) health. →
8. [ADMINISTER CHILD HEALTH SURVEY.]

243

7A) Administer Child
Health Problems.

CHILD CARE
1. Last time we talked, you said that(describe care situation for preschool children)…
Have you made any changes in your child care arrangements since the last interview?
 Yes
 No
2. Since our last interview, have you had to miss work or a training program
because of a childcare problem?
 Yes →
9A) How did your supervisor react?
 No
PARENTING
1. Overall, how do you feel about the amount of support you have for parenting in your life?
PERSONAL WELL-BEING
1. Last year, you said the thing you were most looking forward
to was______________.
How is that going?
{OR WHATEVER THE APPROPRIATE FOLLOW-UP
QUESTION(S) MAY BE.}
2. I’d like to ask you a few questions about how things are going
for you personally.
[ADMINISTER FEELINGS ABOUT HOW THINGS ARE
GOING MEASURE.]
3. Overall, how satisfied are you with your life right now?
[CIRCLE NUMBER OF RESPONSE]
5 Very satisfied
4 Satisfied
3 Mixed feelings
2 Dissatisfied
1 Very dissatisfied

244

Well-Being notes from
previous interviews:

Now I’d like to ask you a few questions about how things are going for you with the family
members living in your household.
4. I am satisfied that I can turn to my family for help when something is troubling me.
4 always
3 almost always
2 some of the time
1 hardly
0 never
5. I am satisfied with the way my family talks over things with me and shares problems with me.
4 always
3 almost always
2 some of the time
1 hardly
0 never
6. I am satisfied that my family accepts and supports my wishes to take on new activities or
directions.
4 always
3 almost always
2 some of the time
1 hardly
0 never
7. I am satisfied with the way my family expresses affection and responds to my emotion, such
as anger, sorrow, or love.
4 always
3 almost always
2 some of the time
1 hardly
0 never
8. I am satisfied with the way my family and I share time together.
4 always
3 almost always
2 some of the time
1 hardly
0 never
9. What would make life better for your family? Why do you feel that way?

245

SUMMARY
1. Think of an ideal community for you and your children. What change in this community
would make the biggest improvement for families like yours? (Probe: For example, would you
like to see changes in the school system, job opportunities, health care, services that are available
in the community…)
2. If there were job training programs or education programs in this community, do you think
that you or your partner would be interested? How would you like to find out about programs
like this in the community? What might keep you from being involved in a training program
right now?
3. In what ways has participating in this study affected your life?

246

There are many community services that families need to know how to access. The services
needed are different for each family. If you needed it, would you know where to go to:
Table C. 1. Knowledge of Community Resources
Service

Yes

1.

Get help on heating bills

2.

Apply for subsidized housing

3.

Find temporary housing

4.

Apply for Medicaid/MA

5.

Find help for a drug or alcohol problem

6.

Find help for a domestic violence problem

7.

Get your child immunized

8.

Find a family doctor

9.

Find dental care

10

Find a mental health counselor

11.

Find family planning services

12.

Apply for welfare

13.

Get legal assistance

14.

Apply for food stamps

15.

Apply for WIC

16.

Locate job training

17.

Find transportation choices

18.

Find child care

19.

Apply for a child care subsidy

20.

Find help for a family member with disabilities

21.

Find low-cost clothing for your family

22.

Find Cooperative Extension Service activities (4H, etc.)

23.

Find Loans to assist you

24.

Find sources of financial assistance

25.

Obtain assistance in using the Internet

26.

Use the Internet

247

No

FOOD SECURITY MODULE
These next questions ask about the food eaten in your household in the last 12 months, since
(current month) of last year, and whether you were able to afford the food you need.
1. Which of these statements best describes the food eaten in your household in the last 12
months? [READ LIST, CIRCLE NUMBER OF RESPONSE]
[1] Enough of the kinds of food we want to eat. [Go TO Q2]
[2] Enough but not always the kinds of foods we want. [GO TO Q1b]
[3] Sometimes not enough to eat [GO TO Q1a]
[4] Often not enough to eat [GO TO Q1a]
[5] DK or no answer [Go TO Q2]
1a. [IF ANSWERED 3 OR 4 ABOVE] Here are some of the reasons why people don’t always
have enough to eat. For each one, please tell me if that is a reason why you don’t always have
enough to eat. [READ LIST, CIRCLE RESPONSE]
Not enough money for food......................................... ............................... YES
Not enough time for shopping or cooking .................................................. YES
Too hard to get to the store ........................................................................ YES
On a diet ................................................................................................... YES
No working stove available ....................................................................... YES
Not able to cook because of health problems ............................................. YES

NO
NO
NO
NO
NO
NO

DK
DK
DK
DK
DK
DK

1b. [IF ANSWERED 2 ABOVE] Here are some reasons why people don’t always have the
quality or variety of food they want. For each one, please tell me if that is a reason why YOU
don’t always have the kinds of food you want to eat. [READ LIST, CIRCLE RESPONSE]
Not enough money for food....................................................................... YES
Kinds of food we want not available.......................................................... YES
Not enough time for shopping or cooking .................................................. YES
Too hard to get to the store ........................................................................ YES
On a special diet .............................................................. ........................... YES

NO
NO
NO
NO
NO

DK
DK
DK
DK
DK

[ASK ALL RESPONDENTS] Now I’m going to read you several statements that people have
made about their food situation. For each of these statements, please tell me whether the
statement is often true, sometimes true, or never true for your household in the last 12 months,
that is, since last (name of current month).
2. The first statement is: “We worried whether our food would run out before we got money to
buy more.” Was that often true, sometimes true, or never true for your household in the last 12
months? [CHECK RESPONSE BOX]

248

3. “The food that we bought just didn’t last, and we didn’t have money to get more.” Was that
often, sometimes, or never true for your household in the last 12 months?

4. “We couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for
your household in the last 12 months?
er true
5. I (we) relied on only a few kinds of low-cost food to feed my (our) children because I was
(we were) running out of money to buy food.” Was that often, sometimes, or never true for your
household in the last 12 months?
Often true

6. I (we) couldn’t feed my (our) child (children) a balanced meal because I couldn’t afford
that.” Was that often, sometimes, or never true for your household in the last 12 months?
ften true

[IF ANSWERED NEVER TRUE TO ALL 5 OF THE ABOVE QUESTIONS (Q2 THRU
Q6), AND ANSWERED “1” OR “2” TO Q1, STOP HERE. OTHERWISE CONTINUE.]
7. My (our) child (children) was (were) not eating enough because I (we) just couldn’t afford
enough food. Was that often, sometimes, or never true for your household in the last 12 months?

8. In the last 12 months, since last (name of current month), did you (or other adults in you
household) ever cut the size of your meals or skip meals because there wasn’t enough money for
food?
[GO TO Q8a]
[GO TO Q9]
[GO TO Q9]
249

8a. [If YES] How often did this happen – almost every month, some months but not every
month, or in only 1 or 2 months?

9. In the last 12 months, did you ever eat less than you felt you should because there wasn’t
enough money to buy food?

10. In the last 12 months, were you ever hungry but didn’t eat because you couldn’t afford
enough food?

11. In the last 12 months, did you lose weight because you didn’t have enough money for food?

[IF ANSWERED NO TO ALL OF THE 4 PREVIOUS QUESTIONS (Q8 THRU Q11),
STOP HERE. OTHERWISE CONTINUE.]

250

12. In the last 12 months, did you (or other adults in your household) ever not eat for a whole
day because there wasn’t enough money for food?
[GO TO Q12a]
[GO TO Q13]
[GO TO Q13]
12a. [If YES] How often did this happen – almost every month, some months but not
every month, or in only 1 or 2 months?

13. The next questions are about children living in the household who are under 18 years old. In
the last 12 months, since (current month) or last year, did you ever cut the size of your child’s
(children’s) meals because there wasn’t enough money for food?

14. In the last 12 months, did any child ever skip meals because there wasn’t enough money for
food?
Yes [GO TO Q14a]
[GO TO Q15]
[GO TO Q 15]
14a. [If YES] How often did this happen – almost every month, some months but not
every months, or in only 1 or 2 months?
nth

15. In the last 12 months, was any child in the household ever hungry, but you just couldn’t
afford more food?

16. In the last 12 months, did any child ever not eat for a whole day because there wasn’t
enough money for food?

251

1. Do you have medical
insurance?
Yes_____ No_____

ADULT HEALTH SURVEY
9. About how many times
have you seen a doctor or
other healthcare provider
since the last interview?

17. About how many times
have you visited a dentist
since the last interview?
_____________________

2. [If YES] What kind?

Private/HMO

Medicaid/MA

State Health Plan

Other (Explain)

10. [For SAME PARTNER]
About how many times has
your partner seen a doctor
or other healthcare provider
since the last interview?

18. [For SAME PARTNER]
About how many times has
your partner visited a dentist
since the last interview?
______________________

3. Does your partner have
medical insurance?
Yes_____ No_____

11. [For NEW PARTNER]
About how many times has
your partner seen a doctor
or other healthcare provider
in the last year?

19. [For NEW PARTNER]
About how many times has
your partner visited a dentist
in the last year?
______________________

4. [If YES] What kind?

Private/HMO

Medicaid/MA

State Health Plan

Other (Explain)

12. [If NONE] When was
the last time your partner
saw a doctor or other
healthcare provider?

20. [If NONE] When was
the last time your partner
visited a dentist?
______________________

5. Do you have dental
insurance?
Yes_____ No_____

13. Has there ever been a
time when you needed to
see a doctor or go to the
hospital but didn’t go?
Yes____ No_____

21. Has there ever been a
time when you wanted or
needed to see a dentist but
didn’t go?
Yes____ No_____

6. [If YES] What kind?

Private

Medicaid/MA

Other (explain)

14. [If YES] Tell me about
this. _______
_____________________

22. [If YES] Tell me about
this.___________________
______________________

7. Does your partner have
dental insurance?
Yes_____ No_____

15. Has there ever been a
time when your partner
needed to see a doctor or go
to the hospital but didn’t
go?
Yes____ No_____

23. Has there ever been a
time when your partner
wanted or needed to see a
dentist but didn’t go?
Yes____ No_____

8. [If YES] What kind?

Private

Medicaid/MA

Other (explain)

16. [If YES] Tell me about
this. _______

24. [If YES] Tell me about
this.
______________________

252

ADULT HEALTH SURVEY (CONT)
25. Since the last interview,
how many days have you
missed work due to an
illness, injury, surgery, or
pregnancy?
26. [For SAME PARTNER]
Since the last interview, how
many days has your partner
missed work due to an
illness, injury, or surgery?

28. Have you or your
partner ever postponed
filling, or not filled, a
prescription for medicine
for yourselves?
Yes_____ No_____
______________________
29. [If YES] For what
reasons?

27. [For NEW PARTNER]
How many days has your
partner missed work due to
an illness, injury, or surgery
in the last year?

253

30. Have you or your
partner ever used a
medicine differently from
how it was prescribed?
Yes_____ No_____
31. [If YES] For what
reasons? ____

First name of: Child 1:________________
_________________

Child 2: ________________

Child 3:

CHILD HEALTH SURVEY
1.Does C1 have medical
insurance?
2.[If YES] What kind?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
__________
3.Does C2 have medical
insurance?
4.[If YES] What kind?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
__________
5.Does C3 have medical
insurance?

11.Does C1 have any type of
12.[If YES] What kind?

Private

Medicaid/MA

Other (Explain):
____________
___________________
______

13.Does C2 have any type of
14.[If YES] What kind?

Private

Medicaid/MA

Other (Explain):
____________
___________________
______
15.Does C3 have any type of

6.[If YES] What kind?

Private/HMO

Medicaid/MA

State Plan

Other (Explain):
__________
7.About how many times
has your child been to a
doctor or other health care
provider since the last
interview?
C1 _______ C2 ______ C3
_______

16.[If YES] What kind?

Private

Medicaid/MA

Other (Explain):
____________
___________________
______
17.About how many times since
the last interview has your child
visited a dentist?
C1 _______ C2 _______ C3
______
18.[If NONE] When was the
last time your child visited a
dentist?
254

21.Has there ever been a
time when your child
needed to see a dentist
but didn’t go? [Record
yes or no.]
C1 _____ C2 _____ C3
____
22.[If YES] Tell me
about this.
C1__________________
____
C2__________________
____
C3__________________
____
23.Have you or your
partner ever postponed
filling, or not filled, a
prescription for medicine
for your child?
[Record yes or no.]
C1 _____ C2 _____ C3
____
24.[If YES] Tell me
about this.
___________________
____________________
___
____________________
___
25.Have you or your
partner ever given a
medicine to your child
differently from how it
was prescribed?
[Record yes or no.]

8.Has there ever been a time
when your child needed to
see a doctor or go to the
hospital but didn’t go?
[Record yes or no.]
C1 _______ C2 _______ C3
_______
9.[If YES] Tell me about
this.
C1____________________
________
C2____________________
________
C3____________________
________
10.Since the last interview,
about how many days has
your child missed school or
daycare due to an
illness/injury?
C1:
_____________________
C2:
_____________________
C3:
_____________________

C1 ________ C2 _______ C3
______
19.[If approx. date given]
When will your child next
visit a dentist? Please
explain.
C1_____________________
______
C2_____________________
______
C3_____________________
______
20.[If has NEVER visited
dentist] For what reasons has
your child not been to a
dentist?
C1
_______________________
____
C2
_______________________
____
C3
_______________________
____

255

C1 ____ C2 ____ C3
____
26.[If YES] Tell me
about this.
___________________
____________________
___
____________________
___
27.Since the last
interview, how many
days have you missed
work because your
child(ren) was/were ill,
injured, or recovering
from surgery?
___________
28.Since the last
interview, how many
days has your partner
missed work because
your child(ren) was/were
ill, injured, or recovering
from surgery?
_______________

ADULT HEALTH PROBLEMS
[ADMINISTER TO NEW PARTNER]
In the past 3 years, has your partner experienced any of the following health problems?
Partner
Heart Problems
High Blood Pressure
Diabetes





Cancer
Digestive Problems
Liver Problems
Seizure Disorder
Depression/Anxiety







Anger Management
Hepatitis
Allergies
Asthma
Frequent colds/flu/sinus
Thyroid Problems
Kidney Problems
Fatigue
Eye or vision problems
Back Problems
Emotional, physical,
or sexual abuse

Partner
Joint Problems

Chronic Pain

Eating Disorder/
Overweight

Skin Problems

Permanent Disability 
Sexually Transmitted
Disease

Reproductive
Problems

Bladder Infections

Drug Problem

Alcohol Problem

Tobacco Use

Anemia

Migraines/Headaches 
Learning Disabilities 
Arthritis
Other (specify)\ __________________













256

CHILD HEALTH PROBLEMS
[ADMINISTER TO NEW CHILD/CHILDREN]
First name of: Child __: ______________Child __: ______________
Child __: _______________
In the past 3 years, has your child experienced any of the following health problems?
C__ C__ C__
C__ C__
Allergies



Head Lice


Anemia



Behavior Problems


Asthma



Conjunctivitis (pink eye) 

Cancer



ADD/ADHD


Chronic Pain



Fetal Alcohol Effects/
Learning Disability 


Syndrome


Depression/Anxiety 


Fetal Drug Effects


Anger Management 


Broken Bones


Diabetes



Sexually Transmitted
Digestive Problem



Disease


Drug Problem



Skeletal Problems


Alcohol Problem



Tobacco Use


Ear Infections



Migraines/Headaches


Eating Disorder/
Permanent Disability


Obesity



Other (specify)
__________________
Eye/Vision Problems 


__________________
Fatigue



__________________
Frequent colds/flu/
sinus



Hepatitis



Seizure Disorders



Skin Problems




257

C__













Short Form 36 (SF-36)
1. In general, would you say your health is:
Excellent

Very Good

Good

Fair

Poor

2. Compared to one year ago, how would you rate your health in general now?
Much better now than one year ago

Somewhat better now than one year ago

About the same as one year ago

Somewhat worse now than one year ago

Much worse than one year ago

3. The following items are about activities you might do during a typical day. Does your health
now limit you in these activities? If so, how much?
a. Vigorous activities (running, lifting heavy objects, participating in strenuous sports)
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
b. Moderate activities (moving a table, pushing a vacuum cleaner, bowling)
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
c. Lifting or carrying groceries
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
d. Climbing several flights of stairs
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
e. Climbing one flight of stairs
Yes, limited a lot

Yes, limited a little 
No, not limited at all 

258

f. Bending, kneeling, or stooping
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
g. Walking more than a mile
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
h. Walking several blocks
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
i. Walking one block
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
j. Bathing or dressing yourself
Yes, limited a lot

Yes, limited a little 
No, not limited at all 
4. During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health?
a. Cut down the amount of time you spent on work or other activities.
Yes 

No



b. Accomplished less than you would like.

Yes



No



c. Were limited in the kind of work or other activities.

Yes



No



d. Had difficulty performing the work or other activities.

Yes



No



5. During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)?
a. Cut down the amount of time you spent on work or other activities.
Yes 
259

No



b. Accomplished less than you would like.

Yes



No



c. Didn’t do work or other activities as carefully as usual.

Yes



No



6. During the past 4 weeks, to what extent has your physical health or emotional problems
interfered with your normal social activities with family, friends, neighbors, or groups?
Not at all

Slightly

Moderately 
Quite a bit

Extremely

7. How much bodily pain have you had during the past 4 weeks?
None

Very mild

Mild

Moderate

Severe

Very severe 
8. During the past 4 weeks, how much did pain interfere with your normal work (including both
outside the home and housework)?
Not at all

A little bit

Moderately 
Quite a bit

Extremely

9. These questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give the one answer that comes closest to the way you have
been feeling. How much of the time during the past 4 weeks…
a.

Did you feel full of pep?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time








260

b. Have you been a very nervous person?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time








c. Have you felt so down in the dumps that nothing could cheer you up?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time








d. Have you felt calm and peaceful?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time








e. Did you have a lot of energy?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time








f. Have you felt downhearted and blue?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time







261

g. Did you feel worn out?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time








h. Have you been a happy person?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
i.








Did you feel tired?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time








10. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
All of the time
Most of the time
Some of the time
A little of the time
None of the time







262

11. How TRUE or FALSE is each of the following statements for you?
a. I seem to get sick a little easier than other people.
Definitely true

Mostly true

Don’t know

Mostly false

Definitely false

b. I am as healthy as anybody I know.
Definitely true

Mostly true

Don’t know

Mostly false

Definitely false

c. I expect my health to get worse.
Definitely true

Mostly true

Don’t know

Mostly false

Definitely false

d. My health is excellent.
Definitely true
Mostly true
Don’t know
Mostly false
Definitely false







263

For each of the following statements, check the box that best describes HOW OFTEN YOU
HAVE FELT THIS WAY DURING THE PAST WEEK.
Table C. 2. Feelings About How Things Are Going
Rarely
or
none of
the time
1. I was bothered by things that don’t usually
bother me
2. I did not feel like eating; my appetite was poor
3. I felt that I could not shake the blues even with
help from my family and friends
4. I felt that I was just as good as other people
5. I had trouble keeping my mind on what I was
doing
6. I felt depressed
7. I felt that everything I did was an effort
8. I felt hopeful about the future
9. I thought my life had been a failure
10. I felt fearful
11. My sleep was restless
12. I was happy
13. I talked less than usual
14. I felt lonely
15. People were unfriendly
16. I enjoyed life
17. I had crying spells.
18. I felt sad
19. I felt that people disliked me
20. I could not “get going”

264

A little
of the
time

A
moderate
amount
of
time

Most or
all of
the time

REFERENCES

265

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