THESi3 illlillllllllllllllllillilillllillllllllllllillUllilllllllll 3 1293 01568 3365 ’ V LIBRARY Michigan State University This is to certify that the ; thesis entitled Relationship Of Changes In Functional Social Support And Depressive Symptomatology From Prenatal To Post Partum In Low Income Women presented by ' Sandra Lynn Boomer has been accepted towards fulfillment of the requirements for Mas ters omciemenegree in _Nm:sing_ Major professor MS U is an Affirmative Action/Equal Opportunity Institution PLACE N RETURN BOX to rornovo thio chockoui from your rocord. TO AVOID FINES. rotum on or boioro doto duo. _§ DATE DUE DATE DUE OmEm DUE ” OCT I Ly I T} D o gifw‘s (b .. 2004 W iii 1 MSU is An Alhrmotivo ActionlEquoi Opportunity lnotituion Wins-9.1 .——.—_.___._—f ,7 7 i RELATIONSHIP OF CHANGES IN FUNCTIONAL SOCIAL SUPPORT AND DEPRESSIVE SYMPTOMATOLOGY FROM PRENATAL TO POST PARTUM IN LOW INCOME WOMEN BY Sandra Lynn Boomer A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1997 ABSTRACT RELATIONSHIP OF CHANGES IN FUNCTIONAL SOCIAL SUPPORT AND DEPRESSIVE SYMPTOMATOLOGY FROM PRENATAL TO POST PARTUM IN LOW INCOME WOMEN BY Sandra Lynn Boomer Depressive symptomatology in pregnancy and the post partum period does occur for some women. The purpose of this study was to determine the relationship of changes in functional social support and depressive symptomatology from prenatal to post partum. It was hypothesized that there was a relationship between changes in functional social support and changes in depressive symptomatology from prenatal to post partum. The sample was 36 women who completed questionnaires on functional social support and depressive symptomatology. This study will provide baseline information to maternal health care providers about social support and depressive symptoms. It may be used in the development of new instruments for future studies with larger samples. Nursing practice would benefit from findings on these topics by enabling changes in care guidelines and teaching modalities. ACKNOWLEDGMENTS I would like to thank my thesis chairperson Rachel Schiffman RN,PhD., for assisting me with deadline management and emotional support and my thesis advisors, Mildred Omar RNC, PhD., and Linda Beth Tiedje RN, PhD., for their valuable support and advice. A special thank you to my husband, Charlie, my daughters Andrea, Leslie and Erin, and my mother, who provided the strength and support I needed to accomplish this task. Without my family and our "thesis group" (Andi, Louann, Kathy, Jan and Deb) this thesis might never have been completed. iii TABLE OF CONTENTS LIST OF TABLES00000000 OOOOOOOOOOOOOO 00000000000000.0000000Vi LIST OF FIGURES00000000 ..... 00000000000000000000000000000Vii INTRODUCTION............... ..... ...........................1 Study Relevance.......................................5 Research Question.....................................6 Hypothesis............................................6 CONCEPTUAL DEFINITIONS. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 DepreSSive symptomatOIOgy 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 Functional SOCial support 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12 REVIEWOF LITERATURE0000000000000000000000000000000000000014 critique0000000000000000000000000000000.000000000000020 THEORETICAL FRAMEWORK00000000000.0.000.000000000000000000022 Personal System........ ..... .. ........ ...............22 Interpersonal System... ..... .........................26 METHODSO 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ...... 0 0 0 29 Research Design...... ............ ....................29 sample. 0 0 0 0 0 0 I 0 O O O O O 0 0 O 0 O O 0 O 0 O O O O O O 0 0 O 0 O O O 0 O 0 0 0 0 O 0 0 0 0 29 INSTRUMENTS...............................................30 Center for Epidemiologic Studies Depression (CES-D) Scale........................................30 Norbeck Social Support Questionnaire (NSSQ)..........32 Operational Definitions of Variables.................33 Data Collection......................................34 Data Analysis........................................35 Protection of Human Subjects.........................35 Assumptions............................. ...... .......35 Limitations..........................................36 RESULTSOOOO00000000000000000000000000000 ........... 000000036 Demographics 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000 0 0 0 0 0 0 0 3 6 Findings 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000 0 0 0 0 0 0 0 0 0 0 0 38 iv Table of Contents Continued DISCUSSION..... ....... ...................... ....... .......4l IMPLICATIONS................ ....... .......................49 Practice.............................................49 Future Research......................................52 Summary..............................................55 APPENDICES Appendix A: UCRIHS approval and consents to publish Factors Influencing Pregnancy Outcome 3/92......52 Factors Influencing Pregnancy Outcome 3/93......53 The Relationship of Changes in Functional Social Support and Depressive Symptomatology From Prenatal To Post Partum in Low Income Women 7/96...............................54 Permission to use table Symptoms of Problems in Postpartum Adjustment ,0. Gruen..............55 Appendix B: Social Support Questionnaire.............56 Appendix C: CES-D Scale..............................61 Appendix D: Procedure for Data Collection............62 LIST OF REFERENCES000000000000000000000000000000000000000064 Table Table Table Table Table LI ST OF TABLES Symptoms of Problems in Postpartum Adjustment....10 Demographic Characteristics of Women with Complete and Incomplete Data.....................37 Measurements of Variables CES-D and NSSQ Pregnant and Post Partum n = 36..................39 Changes in Scores for Depression and Social Support From Prenatal to Post Partum (n:37)00000.000000000000000000000000000040 Cross Tabulation of Changes in Functional Social Support and Depressive Symptomatology for Prenatal and Post Partum (n = 36) ..... ...... 40 vi LIST OF FIGURES Figure 1. An adapted conceptual framework for nursing: dynamic interacting systems........................ .......... . ...... 24 vii INTRODUCTION Pregnancy is a time when changes occur in a woman's body. Most women find these changes exciting and expected. Changes of pregnancy are usually anxiously anticipated and family and friends share in this experience, providing a woman with functional social support for this event. One change that is not expected or welcome is the appearance of depressive symptomatology. Depressive symptoms can appear during the pregnancy and for a time after the birth of the infant. "Postpartum psychiatric disorders have been recognized since the time of Hippocrates, when the function of lactation was thought to be the origin of problems that follow childbirth" (Gruen, 1990, p. 261). The purpose of this study was to determine the relationship between changes in functional social support and changes in reported depression scores from prenatal to the post partum visits. Pregnant and post partum women have many changes occurring in their lives, some physical and some emotional. Support from friends, family and spouse can make these alterations in life manageable. The need and desire to have a support system are defined individually. To one woman, the ability to have someone with whom to discuss and 2 problems is sufficient. To others help with domestic chores, constant physical presence of a support person and continual reinforcement is needed to feel supported. A functional social support system may be essential for pregnant women. The value of such support is determined by for each woman. This makes it necessary for health care providers to address this subject with clients individually. An alteration in the functional social support system may be a factor that contributes to the woman's feelings of depression. The symptoms of depression can intensify if a woman does not have social support and encouragement from family and friends. Mercer & Ferketich (1988) found that social support was a determinant for depression during pregnancy but there is much needed work determining differences in social support constructs. "Depression during pregnancy and its contributing factors have not been studied extensively. Depression among poor pregnant women has received even less attention" (Sequin, Potvin, St. Denis, & Loiselle, 1995, p.583). The hormonal and emotional changes that occur during pregnancy can mimic depressive symptoms (Zuckerman, Amaro, Bauchner & Cabral, 1989). Frequent mood swings, anxiety, fearfulness, loss of energy, sleep difficulties, loss of interest in usual activities, decreased sexual desires and poor appetite are all possible symptoms of depression in pregnancy (Philipp, Maier & Delmo, 1990). The overlap in symptoms or changes indicates why health care providers may miss 3 symptoms of depression in pregnant women. Limited studies indicate that clinical depression during pregnancy is reported in 4% to 16% of pregnancies while depressive symptomatology occurs in as many as 30% to 38% of all pregnant women (Zuckerman et al., 1989). These findings can be significant when relating them to pregnancy outcomes. Depressive symptoms such as loss of appetite can influence the birth weight of an infant. Women who are clinically depressed may be more inclined to smoke cigarettes, drink alcohol or use drugs to alter their mood; these all have deleterious affects on the fetus (Steer, Scholl, Hediger, & Fischer 1992: Zuckerman et al., 1989). Support of family and friends is perceived differently by each individual, according to the importance of functional social support. One perception might be unwanted functional social support. The pregnancy may cause personal resentments, interference of in-laws or friends, or dependency on others due to illness during pregnancy. Another perception would deal with a lack of available functional social support. The support of family and friends may not be as available as the pregnant woman needs or desires. Should this happen, the pregnant woman may be at risk of developing depressive symptoms because perceived needs of social support have not been met. Functional social support may not provide the woman with what she wants for functional social support. The problem may arise from a difference of what is wanted for functional social support and what is available. Depression in the post partum period is a complex phenomenon involving three categories. Post partum blues occur after delivery of the infant to 10 days post partum. The blues are usually a short term problem but if not resolved can lead to post partum depression. Post partum depression can occur during pregnancy and up to one year post partum. Post Partum depression is treated with medication and outpatient counseling. Psychotic depression is depression requiring intense medical care with possible hospitalization and medication. Women with psychosis may have a past history of depression and it could indicate an ongoing, unresolved medical problem. Factors influencing depression vary with each woman (Gruen, 1990). Some women will not experience this problem while others are at risk for postpartum depression especially when there is a lack of social support (Wolman, Chalmers, Hofmeyr, & Nikodem, 1993). Research is not sufficiently covering the problems associated in depression in pregnancy and post partum. There is little information studying social support and the effect on depressive symptomatology occurring during pregnancy and post partum. The problem of depression can have effects on the pregnancy and fetal outcome making this important to research. The purpose of this study is to look at the relationship of these variables and determine if there is a change that occurs in either the social support or depressive symptomatologies. Study Relevance Several factors may contribute to post partum depression. The physiologic component due to hormonal changes may result in weight loss, appetite loss, feelings of loneliness and hormonal changes. The past history component includes family history of mental illness, previously diagnosed depression, and abuse. Support of family and friends may effect a woman’s emotions and help diminish depressed need (Zuckerman et al., 1989). Depression or depressive symptoms may have a direct relationship on pregnancy outcome by leading to substance abuse involving cigarettes, alcohol, marijuana or other illicit drugs (Zuckerman et al., 1989). Depression may be a problem that can negatively influence the well being of the fetus and the family unit. Nurses in advanced practice are educated to evaluate and help minimize the possible complications that may occur when depression affects pregnant women. The social support of pregnant women is an important factor that needs to be evaluated. Advanced Practice Nurses (APN) are able to assess and develop interventions for both functional social support and depression for pregnant women. The APN is in a position in the health care system to intervene when necessary. The skills of the APN can provide the appropriate interventions to pregnant and post partum women. Early detection of potential problems regarding social support can help eliminate later problems such as 6 depression. The APN has the opportunity to educate and counsel the client and family. The APN may assist the client and family in recognizing problem areas and mutually setting goals. Through education and counseling, the client will become more adept at recognizing areas of depression and deficits in functional social support. The client can then strengthen these areas to deal with future problems. The APN is then able to follow the plan of care and evaluate its effectiveness for each woman. Working collaboratively with the physician, social worker, psychiatrist, psychologist or any other referral the woman may need, enables the health care team to provide individualized and personal care for each client. se 5 Is there a relationship between changes in functional social support and changes in depressive symptomology from prenatal to postpartum? Wis There is a statistically proportional difference between women who have an increase, decrease, or no change in functional social support and women who have increases, decreases, or no change in depressive symptomatology from prenatal to post partum. CONCEPTUAL DEFINITIONS W Depressive symptomatology is symptoms of depression that a client perceives or reveals to the examiner. The 7 symptoms are signals of a change in the client’s emotional well being. These symptoms can occur at any stage of the life cycle and are not specific to the female gender. Symptoms can be minimal, allowing the client to deal with issues without medical assistance, or they can be clinically significant requiring medical interventions including medication and or psychotherapy. Each person exhibits a unique presentation of depression. Symptoms can include frequent mood swings, anxiety, fearfulness, loss of energy, sleep difficulties, loss of interest in usual activities, decreased sexual desires and poor appetite (Philipp et al., 1990). The components of depressive symptomatology consist of depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite and sleep disturbance (Radloff, 1977). These components can be utilized to assist in the diagnosis at any stage of life, even during pregnancy. The symptoms of pregnancy including loss of sleep, poor appetite, frequent mood swings, anxiety, fearfulness, loss of energy and decreased sexual desire overlap with depressive symptomatology. The overlapping of symptoms can interfere with the diagnosis of depression in pregnant women. Clark, Anehensel, Frerichs, and Morgan (1981) state that these depression symptoms can then be grouped into negative affect, positive affect, somatic and retarded activity and interpersonal systems. 8 Utilizing the depression symptomatology described by Radloff (1977), assessing the frequency they occur and the duration of symptoms the clinician is able to develop a diagnosis of depression. These symptoms are a screening tool to assist in diagnosis of depression. Both the depression symptoms used by Radloff (1977) and Beck, Ward, Mendelson, Mock, & Erbaugh, (1961) are utilized to screen the clinical symptoms of depression described in ,D-oros ' . d . _ _. . 1-1,, 0 at,» '.9,2‘ (1994). The classification systems vary in the number of symptoms they utilize but follow the same outlines. Depressive symptomatology represents symptoms that are the key factors for determining depressive states. A person exhibiting a combination of five or more depressive symptoms can be diagnosed as clinically depressed by the health care professional. Care plans and treatment then are evolved for the client. "Diagnosis of depression is appropriate when a minimum of five symptoms, one of which is "depressed mood“ or "loss of interest or pleasure in most or all activities" are present nearly every day for at least two weeks" (Guze & Gitlin, 1994, p. 49). Depressive symptomatologies can affect all stages of the life cycle. For this study the symptomatologies will be related to the prenatal and post partum time frame. Prenatal depression is diagnosed using the same assessment tools as would be utilized in the general population. The problem with diagnosing during pregnancy is that some of the 9 symptomatologies for depression are closely related to symptoms of pregnancy. Fatigue, appetite loss, irritability, crying and sleep disturbances are variables that exist in both depression and pregnancy. These symptoms may occur frequently more than one time a week and last longer than two weeks. These symptoms may be difficult to distinguish as depression symptoms or pregnancy symptoms. Depressive symptomatology in the post partum period to one year post delivery is specific to the new mother and called post partum depression. Symptoms of depression are common in other populations but particularly identified in this group of people because of the time frame in the life cycle. Women’s symptoms after pregnancy can be mild as in the "baby blues" or as clinically significant as post partum psychosis as seen in Table 1. Baby blues are typically dealt with by the woman and family, and rarely require use of medication or psychotherapy. Symptoms are usually transitory, passing with support and adequate care for the mother (Affonso & Domino, 1984). The symptoms in the column "symptoms of post partum depression" (Table 1) are similar to those described by Radloff (1977) and Beck et a1. (1961). The components of depressive symptomatology are grouped into psyiological, psychological and emotional symptoms. The milder symptoms being listed in column one (baby blues) and building upon these as the severity of depression increases. Post partum depression, continued beyond two weeks or Table 1. 10 Symptoms of Problems in Post Partum Adjustment Symtoms of baby blues Symptus of post partum depressiont Symtm of psychosis“ Physical Sleeplessness Headache refusal to eat lack of energy Food cravings or loss of appetite Tiredness even after sleeping Mental Anxiety and worry Great concern over physical changes Confusion and nervousness Feelings such as 'I'm not myself, this isn't me' Lack of Confidence Sadness Feelings of being overwhelmed Table l (cont'd). Numbness, tingling in limbs Chest pain Despondency or despair Feelings of inadequacy Inability to cope Hopelessness, sense of powerlessness Excessive concern over baby’s health Impaired concentration Loss of normal interests Loss of interest in sex Thoughts of suicide Bizarre or strange thoughts or fantasies Feelings of shame, embarrassment or guilt Inability to stop activity Frantic, excessive energy Extreme confusion Lossof memory Incoherence Bizarre Hallucinations (for example, walls moving, animals talking) (table continues) Symptomofbabyblues Symptms of post partum depression Symptrlsofpsydnsisfi 11 Behavior and ractiois More frequent crying Extreme or unusual behavior Suspiciousness Hyperactivity or excitability Panic attacks Irrational statements Oversensitivity, feelings hurt Anxiety Preoccupation with trivia easily Irritability with everyone Hostile or easily angered Lack of feelings for the baby New fears or phobias Hallucinations Nightmares Fxtrue guilt Ho feelings for the baby Overconcern for the baby Anger toward the baby Feelings of being out of control Feelings of 'going crazy' Ho_te_. from 'Post partum depression: a debilitating yet often unassessed problu,‘l be D. s. Gruen, 1990, Homing social Hort. 15(4) p. 664. adapted with permission. *symptoms are in addition to baby blues symptoms. it*Symptoms are in addition to baby blues symptoms and post partum depression symptoms. 12 beginning after two weeks, may need intervention to enable the woman to cope with depressive issues and feelings. "The symptoms are mercurial: there can be sudden onset and decline, which makes them confusing and difficult to diagnose" (Hamilton, 1989, p.3). The symptoms are not constant, which seems to make it difficult for the client to get a feel for their condition. Symptoms may be present at one meeting and not at the next. Symptoms can be missed by the health care provider due to the woman's inability to relate problems. The depression symptoms may be confused with those symptoms that are similar to fatigue in caring for a small child. A mixture of all or only a few of the symptoms may be very evident, or easily hidden. This decreases the care providers’ ability to accurately assess and diagnose the condition. For the purpose of this study, depressive symptomatology was defined as those symptoms perceived by the client as occurring one or more times during the week prior to data collection. The components include depressive changes in client’s mood, feelings of guilt or worthlessness, feelings of helplessness, psychomotor retardation, loss of appetite and sleep disturbance. F ' a c' Functional social support is the support the woman perceives she receives from others. It may be from family support given by her spouse, parents, children and friends. 13 It may be professional support offered by health care professionals, social services, church or other outside agencies. Functional social support, when effective, can assist women with the emotional, financial and social issues of pregnancy. Functional social support is usually considered to have a positive effect on the process of pregnancy and the neonates outcome. "... [S]ocial support in the past has been considered primarily a moderation effect on the psychological stress, whereas it actually may be a contributing factor in some high-risk subpopulations" (Saks, Frank, Lowe, Berman, Naftolin, Phil, & Cohen, 1990, p.791). Social support has a moderating effect on psychological stress affecting the pregnancy outcome by lessening stress. An example of a factor of functional social support contributing to a negative outcome might be in the pregnant adolescent pressured by peers to smoke, drink or take drugs. The social network individuals have is unique to them. A social network involves not only the immediate family and friends but those people or groups that influence the individual. The influential parties might be church groups, social workers, doctors, nurses, governmental agencies or any number of individual or services that contribute to the person's well being. Functional social support has three components: affect, affirmation and aid. Kahn (1979) stated that affect is interpersonal transactions that represent respect, l4 admiration and liking: affirmation is agreement or consensus with others: and aid represents assistance through information, material items or personal time (Kahn, 1979). These components are how functional social support is defined in the study. The functional social support variable is a combination of the affect, affirmation and aid scores. The combined scores are the value used for the functional social support variable in this study. The components, affect, affirmation and aid, are not of interest as individual variables for this study. Individuals interpret functional social support differently. Some individuals find that they are not dependent on others to a large degree, while others need constant reassurance and guidance. "The process by which individuals appraise the quality or adequacy of social support may be influenced by personal characteristics, including self esteem, need affiliation and locus of control" (Cutrona, 1989). REVIEW OF LITERATURE The available literature examines the concepts individually looking at causality but minimally examines relationships. The concept of change its relationship to depressive symptomatology and functional social support was not found in the literature. The variety of literature available is extensive for some of the concepts such as post partum depression and functional social support. The 15 literature for prenatal depression and functional social support is not as abundant. Information on prenatal depression is not prevalent in the literature. O’Hara, Schlechte, Lewis 8 Wright (1991) found that women who had higher levels of depressive symptoms during pregnancy, had one previous episode of depression, or had premenstrual depression were at greater risk for post partum depression. In their study 25% of the women met the Handley (Handley Blues) criteria for depression. Handley Blues criteria was based on the work of Handley, Dunn, Waldron & Baker (1980). The severity of seven symptoms occurring during the first ten days post partum were examined. The symptoms were assessed retrospectively at nine weeks post partum (O'Hara et al., 1991). Twenty one percent of the women meeting the Visual Analogue Scales (VAS) for depression criteria experienced postpartum depression. VAS is derived from work from Kendell, McGuire, Conner, and Cox (1981) and Cox, Conner, Henderson, McGuire ,and Kendell (1983) and contained thirteen individual scales that looked at mood states. VAS has been used in previous studies of post partum bluestand depression (Cox et al., 1983: Kendell et al., 1981). Women who met the Handley Blues Criteria had higher levels of depressive symptoms during the second trimester than women who did not meet this criteria (3 = -2.76, d: = 180, p < .01). Similar findings were observed in those women in the VAS criteria 16 Sequin et al. (1995) found a link between inadequate functional social support and depressive symptomology during pregnancy. Women with inadequate functional social support seemed to be at risk throughout childbearing for depression. The Sequin et al. (1995) study compared women of low socioeconomic status with women of higher socioeconomic status. Results at 30 weeks showed that poor pregnant women (n = 98, 46.9%) scored 10 or more on the EDI and often more severely than women who were of higher economic status (n 46, 6.4%) and 20% scored 10 or more. The study showed that depressive symptoms during pregnancy are more common in low income women and there is a strong relationship with these symptoms and socio- environmental factors. These symptoms are increased when the pregnant woman has perceived a need for social support at both economic levels. The findings from this study are particularly valuable for those women who are able to perceive needs of social support. Sequin et al. (1995) cited depression symptoms in 17.3% of low income women to be in the moderate or severe level of depressive symptomatology and 46.9% to be high in depressive symptomology. In the high socioeconomic group, 20% scored high on depressive symptomatology. Only 2.2% of the high socioeconomic group scored in the moderate range and none of them scored in the severely high group. During pregnancy depression has been associated with adverse health behaviors such as smoking (Steer et al., 17 1992). Steer et al.(l992) found an increased risk of inner city adult gravidas (n = 389) to deliver low birth weight (LBW), preterm or small for gestational age babies associated specifically with the degree of self reported depression by the Beck Depression Inventory (BDI). A BDI score of 16-20 indicated dysphoria and scores at or above 21 identify presumptive clinical depression. The proportion of LBW infants for the adult gravidas with BDI score at or above 21 was 20.0% as opposed to 7.6% for those with a BDI less than 21. Poor pregnancy outcomes rose 5% to 7% for each point the BDI score rose and the odds were three times greater if the score was 21 or above. . Zuckerman, Bauchner, Parker and Cabral (1990) studied newborn irritability in babies born to mothers with depressive symptoms. They found mothers with symptoms of depression during pregnancy are more likely to have irritable babies. Their study did not have a cut off score for depression in pregnancy. The scores were divided into percents of the total number of women who delivered term infants (3 = 1123). This indicates that if the CES-D score of 16 identifies depression, then 75% of the women were experiencing some depression during pregnancy. The CES-D scores were compared to self reported past history of depression or suicide attempts. Zuckerman et al. (1990) found that women with a pre pregnant history of depression for two or more weeks had higher CES-D scores (23.3 vs. 16.1 (p < 0.001). 18 Zuckerman et al. (1989) found the CES-D score prenatally for 1014 subjects to be a median score of 16, and a mean of 18.6 (SD 10.8). Zuckerman also utilized the Norbeck Social Support Questionnaire to analyze the social support received by prenatal women. Findings revealed that women with low levels of perceived emotional support reported more depressive symptoms (1 = -.11, p < 0.0001). Literature related to depressive symptomatology in post partum has increased. Prior to the 1980's little information was available on this topic. The subsequent literature contains wide variation in estimates of incidence of post partum depression with studies reporting incidence of 3% (Wolman, 1993) to 52% (Nicolson, 1990). The previously stated studies have been reviewed and there appears to be no consensus on the percentage of women who experience post partum depressive symptomatology. The terms psychological distress, and emotional disequilibrium and depressive symptomatology are used interchangeably in the literature. The variety of information on postpartum depression is available in literature sources from medicine, psychiatry, social work and nursing. Nicolson (1990) studied findings on the causes and correlates of postpartum depression. "The clinical/medical model identifies the mothers as being ill, and the social science model suggests a particular vulnerability to additional social stress factors" (Nicolson, 1990, p.689). Sequin et al. (1995) studied women's depression and 19 Sequin et al. (1995) studied women’s depression and economic status. It was determined that women with a lower socioeconomic status were depressed more frequently and more severely than women with a higher socioeconomic status. Tilden (1983) studied life stress, functional social support and emotional disequilibrium in pregnant women during pregnancy. O’Neil, Murphy, and Greene (1990) studied the prevalence of postnatal depression in 142 women at six weeks post partum using the Cox Edinburgh Postnatal Depression Scale. Thirty eight women scored positive depression and 28 were followed by a psychiatrist. 0f the 28, 20% showed a prevalence of post natal depression. Past psychiatric history was found to be a significant risk factor and there was an association found between post natal depression and delivery by forceps, vacuum or cesarean section. Maternal age and breast feeding had no significant relationship. Tilden (1983) found the effect of functional social support on emotional disequilibrium was significant. This percentage was similar in magnitude to the studies by Lin, Ensel, Simone and Kuo (1979). Lin et al. (1979) studied life stress and functional social support as determinants of (emotional distress) in 170 Chinese-Americans in Washington D.C. and found a positive relationship between life stress and the incidence of symptoms of depression. Significant negative relationships were identified between social support and the incidence of psychiatric symptoms by 20 Lin et al. (1979). Reece (1993) studied functional social support in primiparas over 35 years of age and found that functional support increased with support provided by a spouse/partner both antenatal and post partum. Family and friends followed in the amount of functional support: network support did not change. The social support of spouse, family and friends was associated with lower stress post partum. "Life events as well as inadequate functional social support have been linked to depression in mothers during pregnancy, in early post partum period and during the child's preschool years" (Sequin et al., 1995, p.583). Studies suggest that functional social support may protect psychological well being and mental health by acting as a buffer against stress (Sequin et al., 1995). The literature reviewed indicated a connection between functional social support and depressive symptomatology (Tilden, 1983: Lin et al., 1979; Reese, 1993). The extent to which these factors are influenced by one another is not documented. Change in one concept affects the other but how has not been studied. ; .!. e One limitation noted in these studies identified in the literature review section, is some research utilized small sample size. Larger samples enable researchers to generalize study results and encourage the replication of the studies to increase the credibility of the findings. The literature search did not review any studies 21 differentiating the different types of post partum depressive symptoms. The levels of depression range from post partum blues to psychosis. The components of post partum depression need to be individually evaluated on what effect they have on women. There is a lack of literature on prenatal depression. The information comparing hormonal changes during pregnancy and similarities with depressive symptomatology is lacking. Pregnancy depression is easily missed in pregnancy and a way to evaluate this problem effectively is lacking. There is no literature looking at multiple factors influencing pregnancy and how they relate to depressive symptomology. The study by Sequin et al.(1995) identified low income women as having increased depression. The literature indicates the need to study depression and low income women and women with different cultural backgrounds. Low income women are not identified in many studies as the target population. Some studies have identified a relationship between low income status and an increase in depression scores. The low income women make up a component of the general population and their needs should be studied as a part of the community. If the results of studies are to be generalized to the total population one segment can not be overlooked. There is a gap in the literature on the use of terms such as depression, social support and the time estimated for post partum. These should have a consistent definition 22 to enable research to develop data that is accurate. Researchers using definitions they define for these concepts enable the general researcher to have no constant variable. This would lead information to not be consistent and possible be evaluated incorrectly. This study will fill in the gap relating depressive symptomatologies to the amount of social support. The value of this information will affect the assessments and evaluations made of pregnant and newly delivered women. The relationship of these variables can have a direct effect of care. THEORETICAL FRAMEWORK Functional social support deals with interactions of - family, friends and organizations with whom the person identifies. The effect of functional social support on depressive symptoms involves the person's perceptions of the amount of support obtained. These concepts deal directly with interactions. The theoretical framework developed by King (1981) is composed of three interacting systems. The systems are personal, interpersonal and social. This study was dependent on the interaction of the person with the social network as they defined it, and how this related to depressive symptomatology at two points in time. Interaction is an open system allowing transfer of information both ways within the framework. Personal systems can interact with social systems. Interpersonal systems can interact with both the personal and social 23 systems. The interactions can be in either direction allowing change to occur within each level of the framework. e s s m In King's framework for nursing (Figure l) the inner- most system is the personal system of the pregnant or post partum woman; the individual person with all the fears, worries, hopelessness, appetite losses and other depressive symptomatology that may occur. The woman's body and roles are changing in this system. The system allows for changes in the person, happy, sad, pregnant, not pregnant, and all the other feelings and emotions that make up the person. The changes that occur in depressive symptomatologies during the intrapartum and post partum time period also occur in this system. "The concept of self is perceived in relation to another person and to objects with relevant others gives one a sense of self" (King, 1981, p.27). A new mother or pregnant woman is beginning to identify herself as a different person. The overwhelming feelings of joy and concern over parenting skills, can cause her to doubt her ability to care for the baby. This may change the woman's perception of self. In the personal system positive influences of support from family and friends enable a person to achieve goals and to become self-actualized. Achieving goals and being self actualized would enable a person to move into parenthood easily and cope with changes. Negative influences by others 24 SOCIAL SYSTEMS (Society) HEALTH CARE INSTITUTIONS, SOCIAL SERVICES, ORGANIZATION, CHURCHES, SCHOOLS INTERPERSONAL SYSTEMS PARTNER, PARENTS, FRIENDS, HEALTH CARE PROVIDERS PERSONAL SYSTEMS (Individuals) Low INCOME PREGNANT WOMAN CHANGE OF PRENATAL AND I POST PARTUM DEPRESSIVE SYMPTOMOLOGY SUPPORT SUPPOR’* l— )— 1 Figure 1: An adapted conceptual framework for nursing: dynamic interacting systems (King, 1971, p.20) 25 would be described as smoking or drinking alcohol during pregnancy, not keeping prenatal appointments or contributing to an unhealthy environment in which the individual resides. Negative influences can affect the role of parenting. Influences whether positive or negative are perceived by the person. This perception of influences affect the person's ability to develop positive or negative beliefs or life styles. The way a person develops self is affected by others. Change in self from prenatal to post partum are affected by these influences. The perception of needed social support influence the person in the amount of support they receive. If the person does not desire the support of a partner or family, they will not feel they are being deprived of a personal need. However, if the person feels the need for social support is a contributing factor to the belief in self this will lead them to believe they are deprived of a support that can positively influence them. This deprivation of a personal need can then affect the emotional state of that individual. Depressive symptomatology may be exhibited by the person who feels deprived of personal needs. Depression prenatally and post partum both are in the personal system (figure 1). Depression can affect the interpersonal and social systems by interactions in or between these levels. The primary system dealing with depression is the personal system. 26 I t e na stem In King’s (1981) model, the interpersonal system consist of communication, transaction, roles, and stress. Communication is verbal and non verbal. A pregnant woman might perceive the need for communication about the pregnancy with significant others about the pregnancy. Expectations of the partner may include attendance at doctor appointments, getting excited about fetal movement, understanding her mood changes and having the same loving feelings about the pregnancy. The partner may be experiencing personal feelings of nervousness and apprehension over providing for the family, physical problems the baby may have, financial support for the added family member and a variety of other issues personal. The partner may not be aware of the pregnant woman’s needs or desires. The reaction to these different feelings and emotions might cause mistrust or feelings of isolation in the pregnant woman. The mother is both a giver and taker at different points in time. Roles change from situation to situation. Changes that occur in the personal system affect the interpersonal system. Increased depressive symptomatology in the personal system can affect a change in behavior with those individuals in the interpersonal system. The need for more interaction or less with partner, parents, friends or health care providers becomes evident with change. The system of interpersonal relationships (Figure 1) 27 deals with the person's interaction with their network. The network for the low income pregnant woman is her partner, parents, friends, doctors, nurses, clergy and others. Each individual develops her own interpersonal system. This system may be very small, or very large depending on the individual. Interpersonal systems are the social support systems including parents, friends, partner, and health care providers. Constant interaction between personal systems and interpersonal systems occurs. This study does not look at the interventions of nurses that might occur with changes in functional social support and depressive symptomatology. Further study would need to be done for this to be addressed. Social support begins in the personal system with the perception of need for support. The support then travels from the interpersonal system (Figure 1) to the personal system. This occurs at different levels for each person. Some women have a great deal of interaction between these two systems and others have very little interaction. The amount of exchange depends on the people in both systems. Does the woman desire interaction and are there people in the interpersonal system willing to provide support for the personal system? The social support arrow in Figure 1 goes from interpersonal system to the personal only. This study does not address the social system. If the study did the arrow might fill all systems. For the purpose of this study 28 social support affects only two systems. These systems have a reciprocal relation. The woman must perceive the need for social support, and the interpersonal system must meet the needs of the personal system. King's model enables a woman to look at the surroundings and utilize all elements of life events to affect self if desired. The woman has the ability to change perceptions and be an active participant in the changes that can occur. This process allows change to occur and the self to grow and accept the change in the surroundings. Pregnancy is a time for change and evolution of self to different attitudes, beliefs and perceptions. A woman must undergo may changes when she becomes pregnant. First she must change from an unpregnant individual to a pregnant person and endure the changes that occur in this transition. Upon delivery she once again becomes the unpregnant individual, but not the same person as pre-conception. King’s model is appropriate for this secondary analysis. The social interactions that play a part in personal well being are utilized in this model. The model allows for assessment of the individual and the role interactions played in social support and the perceptions of depressive symptomatology. It also points out that the individual has the ability to interact and change according to the situation she find herself in; this is important when depression is being evaluated. Each individual is capable of dealing with issues unique to them: some are able to 2 9 change the environment around them and some are not. King's model allows open exchange between systems that aid each person individually. One person may need more interaction and assistance than another. The model allows individuals the ability to gain what is needed specifically for personal growth. METHODS Research Design The design utilized for this study was a descriptive correlational study. A secondary analysis approach was used to examine the relationship of changes in functional social support and depressive symptomatology from prenatal to post partum in low income women. The original data were collected in the study "Factors Influencing Pregnancy Outcome in Jackson Center for Healthy Beginnings, Jackson, Michigan" (Schiffman & Omar, 1994). The original study was a prospective study using surveys and chart reviews. The original project was developed to determine the adequacy of prenatal care between women at the Jackson Center and those receiving care with other providers. Demographics affecting care were studied. Data were also obtained from women prenatally and post partum about family functioning, depression, social support, functional status and difficult life events. fiamnls The sample used in this study was a convenience sample of 37 subjects who completed the questionnaires on 30 functional social support and depressive symptoms at both the prenatal and postnatal visits. The subjects were enrolled to receive prenatal care between May 1992 and May 1993. The sample was primarily single and Caucasian women, with at least high school educations. The mean age of the 37 subjects was 22.6 years. Data were obtained prenatally at the second or subsequent prenatal visit and postnatally at the six week post partum visit. INSTRUMENTS Cen -r 0 pie‘ 3! 90' _ 2" Drer‘ '01 _S-D a ‘ The Center for Epidemiologic Studies Depression Scale (CES-D),found in appendix A, was developed to study the epidemiology of depressive symptomatology in the general population (Radloff, 1977). The scale has twenty items to measure current levels of depressive symptomatology, with emphasis on affective component and depressed mood (Radloff, 1977). The components of depressive symptomatology consist of depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, losses of appetite and sleep disturbance.p Four items were worded positively to break tendencies toward response set as well as the ability to assess positive affect (or its absence). CES-D scores correlate with the Zung Depression Scale, Beck Depression Scale, Hamilton Depression Rating Scale and the SCL-90 Depression Scale. Each item is rated by the respondent from zero to three on a scale of frequency of 31 occurrence of the symptoms during a one week time period (Radloff, 1977). The Likert type responses ranged from less than one occurrence per day, to symptoms occurring five to seven days a week. Total scores can range from 0-60 with the higher score indicating greater depressive symptomology. A score of 16 or greater indicates greater depressive symptomology as this approximates the 80th percentile and is an indicator for further assessment. Internal consistency reliability using Cronbach coefficient alpha ranged from .84 to .85 obtained from three national samples (Radloff, 1977 found in Primomo, Yates & Wood, 1990). Internal consistency reliability coefficients have been reported to be .84 or higher across varying age, ethnic and racial groups (Breslau, 1985: Clark et al., 1981; Garrison, Addy, Jackson, McKeown & Waller, 1991: Radloff, 1977: Roberts et al., 1990). The Cronbach's alpha coefficients for the original study were .87 at the prenatal administration and .92 at the postpartum administration (Schiffman & Omar, 1994). The reliability of the scale has been assessed on clinic populations (Craig & VanNatta, 1973: Weisman, Sholomskas, Pottenger, Prusoff, & Locke, 1977) and on respondents from a number of community studies (Comstock & Helsing, 1976; Radloff, 1977: Roberts, 1980). Roberts (1980) reported the scale as reliable when used in Spanish- speaking respondents when interviewed in English or Spanish, and that the factor structure of the scale is similar to 32 that for whites and blacks. Content validity is based on the clinical relevance of the symptoms which comprise the items of the scale. Construct validity of CES-D is based on the known theory and epidemiology of depressive symptoms (Radloff, 1977). The CES-D scale has been tested and was found to be able to differentiate between diagnosed depressed and nondepressed subgroups (Radloff & Locke, 1986; Weissman et al., 1977). Three items in the CES-D scale that might be influenced by pregnancy (Item 2, poor appetite; Item 7, effort: and Item 11, restless sleep) did not demonstrate a different response than other items in the scale in the original study (Schiffman & Omar, 1994). cia uestio na' e N88 The Norbeck Social Support Questionnaire (NSSQ), found in Appendix B, is an instrument to measure multiple dimensions of social support. The NSSQ developed by Norbeck, Lindsey and Carrieri (1981) is based on the conceptual definitions of social support proposed by Kahn (1979). The instrument has three variables based on Kahn's (1979) definition and Barnes' (1972) network theory. The variables identified are total functional support, total network support and total loss. This study utilized only the total functional support component. Functional support components measured are affect, affirmation and aid (Norbeck et al., 1981). The scores for functional components are derived from ratings made by the subject for each person 33 whom they identify in their personal network (Norbeck, Lindsey, Carriere, 1982). The instrument measures perceived support available to individuals rather than reciprocal support mentioned in Kahn’s definition. The first test and retest reveled a seven month moderately high test-retest reliability ranging from .58 to .78 (Norbeck & Tilden, 1983) indicating a moderately high degree of stability over time. The instrument has both high test-retest reliability and internal consistency reliabilities (Norbeck et al., 1982). The interval of one week test retest correlates with a high degree of test- retest reliability (from .85 to .92). The internal consistency coefficient was .88 and indicates homogeneity of the NSSQ instrument (Norbeck et al., 1982). To test validity, the Marlowe-Crowne test of Social Desirability was administered with the NSSQ. The correlations of .01 to .17 ruled out socially desirable response (Norbeck et al., 1981). Concurrent validity is reported through significant positive correlations with the Personal Resource Questionnaire (Brandt & Weinert, 1981) which measures social support. 0 t' e ' ' ' s of V ' b e The variables for this study were depressive symptomatology and functional social support. Depressive symptomology was measured by the Center for Epidemiologic Studies Depression Scale (CES—D) (Appendix C)(Radloff, 1977). Schiffman and Omar (1994) stated that the total 34 scores of CBS-D were calculated from responses with two or fewer missing data prenatally. The total CES-D score was obtained by reverse scoring the four positive affect items, obtaining a mean score and multiplying by 20 (the total number of CES-D items). This was done for both administrations, prenatal and post partum. Change was identified by the total number of the score on the questionnaire there was no pre determined number that would identify the change. Change was determined by using the score obtained at the prenatal questionnaire and comparing that to the post partum score. Increase, decrease or no change was determined by the difference in these scores. Functional social support was measured by the Norbeck Social Support Questionnaire (NSSQ)(Appendix B questions 1 through 6). These scores were based on adding a point for each "yes" answer in questions one through six on the NSSQ. The questions together equal the total functional support. The total score of functional support for this study was determined by adding the three components, affect, affirmation and aid scores together. The scores were then compared prenatally and post partum and subtracted to determine if the scores increased, decreased, or had no change at the post partum visit. W The data for the study were on a data disk provided by the investigators for the original study. 35 Data Analysis The sample population was the 36 women that completed both the CES-D and NSSQ questionnaires at both the prenatal and post partum visits. Women in the original study, that were unable to complete these requirements were eliminated from this study. Data analysis was done using the chi-square statistic with a 2x2 cross tabulation of depressive symptomology with functional social support. The statistical analysis was performed using SPSS-PC software. The chi-square significant level of .05 was set. W The original study was approved by the University Committee on Research Involving Human Subjects (UCRIHS) of Michigan State University (Appendix A). Confidentiality was maintained in both the original and the present study. The identifying data for each subject were filed separately from the original data and were not available to this researcher. Information for this study was obtained on a computer disk. The data for this study were given assigned code numbers and this researcher had no access to the original identifiers. The present study was also approved by UCRIHS (Appendix A). Minus Certain assumptions were made for this study: 1. The women truthfully answered the questions on the questionnaires prenatally and post partum. 2. The original data were collected and entered 36 accurately. 3. Scores were not affected postpartum by the pre exposure to questions on the questionnaires prenatally. 4. All participants were able to read. Limitations Limitations were indicated as follows: 1. Sample size was small, if all the original participants finished the questionnaires the results may have been different. A small sample size decreases the generalizability of the results. 2. The pre-pregnant depression scores were not available for the individuals in the study to determine if that individual was depressed before entering the study. 3. The length of the NSSQ instrument may have decreased accuracy of answers, or increased the number of participants who did not finish the questionnaire, therefore altering the results of the study. 4. Post partum fatigue may have influenced the number of subjects completing the questionnaire and the study. 5. The respondents may have felt pressure to answer questionnaires to receive adequate care. RESULTS Demographics The target sample for this study was taken from the original study, and met the criteria of those that completed both the prenatal and post partum questionnaires (Table 2). Of the 65 women who kept the post partum appointment 37 met Table 2 Demographis Characteristics of Women with Compiepe and Incomplete Data complete incomplete total n = 37 n,= 28 n = 65 No. (%) No. (%) No. (%) AGE 10-19 12(32.4) 10(35.7) 22(33.8) 20-29 20(54.0) 17(45.9) 37(56.9) 30-39 5(13.5) 1 (3.6) 6 (9.2) RACE Caucasian 31(83.8) 21(75.0) 52(80.0) African/Am. 5(13.5) 7(25.0) 12(18.5) Hispanic 1 (2.7) - 1 (1.5) MARITAL STATUS single 25(67.6) 21(67.9) 44(67.7) married/ cohabitating 6(16.2) 7(25.0) 13(20.0) separated/ divorced 6(16.2) 2 (7.1) 8(12.3) EDUCATION ||| H W I‘ll "H ”II” 1| llllHl 31293015683653