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This is to certify that the

thesis entitled

Assessment of the Social Support Relationship
Between Lay Community Volunteers
and Women with At-risk Pregnancy

presented by
Carol Ann Ludwick Powers

has been accepted towards fulﬁllment
of the requirements for

M. S - degree in Nursing

W

Major professor

 

Date Februgri 16, 1998

0-7639 MS U is an Afﬁrmative Action/Equal Opportunity Institution

 

LIBRARY

Michigan State
”University

 

 

 

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DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1/” WMpﬁS—p.“

 

ASSESSMENT OF THE SOCIAL SUPPORT RELATIONSHIP
BETWEEN LAY COMMUNITY VOLUNTEERS
AND WOMEN WITH AT-RISK PREGNANCY
By

Carol Ann Ludwick Powers

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

1998

ABSTRACT
ASSESSMENT OF THE SOCIAL SUPPORT RELATIONSHIP
BETWEEN LAY COMMUNITY VOLUNTEERS
AND WOMEN WITH AT-RISK PREGNANCY
By

Carol Ann Ludwick Powers

This secondary analysis of data described lay volunteers’ assessments of their social
support relationships with at-n'sk pregnant women and investigated associations between
their assessments and psychosocial characteristics and behaviors of the support recipients.
The sample consisted of 64 dyads: predominantly low income and minority support
recipients from an urban setting, and their paired support providers. Providers’
Assessment of the Support Relationship scale scores showed a positive mean assessment
and accounted for a small but signiﬁcant percentage of the variance in the recipient’s
participation in the relationship. Association betWeen provider’s assessment and
psychosocial characteristics of perceived social support, perceived stress, and depression
in the support recipient was not signiﬁcant. The study provides preliminary evidence that
positive support relationships can develop between lay support providers and at-risk
pregnant women and that high perceived stress and depressive symptomatology do not
preclude formation of a positive relationship. The implication for primary care providers is
that the use of lay support providers for augmenting social support may be considered as a

viable option.

To the healthCARE workers in Muskegon, lay community volunteers
who have faithfully kept the vision.
To Dan, for his gifts of encouragement and time,
and for always believing in me.
To Abby and Ben and Elizabeth, our children,
who as fellow students taught me to just do it.
To my parents, who rooted me in caring.

iii

ACKNOWLEDGEMENTS

My thesis chair, Rachel Schiffman, R.N., Ph.D., provided guidance and expertise to
this project from its inception, as well as personal support and encouragement, for which I
am deeply grateful. Barbara Given, R.N., Ph.D., thesis committee member and also my
program advisor, has been an inspiration to me since the ﬁrst class of this masters’
program. I appreciate her insights. Jacqueline Wright, R.N., M.S.N., readily agreed to
serve on my thesis committee in mid-process, and I am thankful for her input.

I would also like to acknowledge the primary investigators for the MOMS Program,
Lee Anne Roman, RN, PhD., Judith Lindsay, B.S.N., M.P.A., and Joseph Moore, M.D.,
for making their data available to me for this secondary analysis. I applaud your vision in
initiating this program. To Marcia Gebben, B.S.N., research coordinator for the MOMS
Program, who worked with me over many months and answered many questions, my

deepest appreciation for your time and cooperation.

iv,

TABLE OF CONTENTS

LIST OF TABLES ................................................... viii
LIST OF FIGURES .................................................... ix
INTRODUCTION ..................................................... 1
Statement of the Problem .............................................. 3
CONCEPTUAL DEFINITIONS ........................................... 5
Assessment of the Support Relationship ................................... 5
Participation in the Support Relationship ................................... 8
Psychosocial Characteristics ............................................ 9
Perceived Social Support ............................................ 9
Perceived Stress .................................................. 10
Depression ...................................................... 11
Adequacy of Prenatal Care ............................................ l l
THEORETICAL FRAMEWORK ......................................... 13
REVIEW OF THE LITERATURE ........................................ l9
Lay Health Worker Social Support Interventions during Pregnancy .............. 19
Evaluation of Support Relationships by the Relationship Participants ............. 22
Social Support related to Adequacy of Prenatal Care ......................... 23
Psychosocial Characteristics of Individuals related to Interaction ................ 24
METHODS .......................................................... 28
Study Design ....................................................... 30
Sample ........................................................... 30
Instruments ........................................................ 31
Assessment of the Support Relationship Scale ............................ 31
Measure of Perceived Support ........................................ 32
Perceived Stress Scale .............................................. 32
Center for Epidemiological Studies-Depression Scale ...................... 33
Operational Deﬁnitions of Variables ..................................... 34
Assessment of the Support Relationship ................................ 34

V

Participation in the Support Relationship ................................ 34

Adequacy of Prenatal Care ........................................... 3 5
Psychosocial Characteristics of the Support Recipient ...................... 36
Procedures ........................................................ 36
Data Analysis ...................................................... 37
Demographics .................................................... 37
Research Question 1 ............................................... 37
Research Question 2 ............................................... 37
Research Question 3 ............................................... 37
Research Question 4 ............................................... 38
Research Question 5 ............................................... 38
Assumptions ....................................................... 38
Limitations ........................................................ 39
Protection of Human Subjects .......................................... 40
RESULTS .......................................................... 41
Sample Description .................................................. 41
Results Related to Research Questions ................................... 43
Research Question 1 ............................................... 43
Research Question 2 ............................................... 43
Research Question 3 ............................................... 44
Research Question 4 ............................................... 45
Research Question 5 ............................................... 46
DISCUSSION ....................................................... 48
Support Recipients .................................................. 49
Demographics .................................................... 49
Psychosocial Characteristics ......................................... 49
Providers’ Relationship Assessments ..................................... 53
Participation in the Support Relationship .................................. 55
Participation in Prenatal Care .......................................... 57
Relationship between Psychosocial Characteristics and Assessment .............. 59

IMPLICATIONS for the ADVANCED PRACTICE NURSE in PRIMARY CARE . . . 61

IMPLICATIONS for FUTURE RESEARCH ................................ 65
SUMMARY ......................................................... 68
APPENDIX A: Instruments ............................................. 70
APPENDIX B: Procedures for Primary Study ............................... 74

vi

APPENDIX C: UCRIHS Approval ........................................ 75
APPENDIX D: Permission to Access Data .................................. 76

APPENDIX B: Table E] Summary of Adequacy of Prenatal Care Utilization Data . . . 77

LIST OF REFERENCES ............................................... 78

vii

LIST OF TABLES

Table l - Frequency and Percent of Demographic Characteristics of
Support Recipients and Support Providers ................... 42

Table 2 - Support Provider’s Assessment of the Support Relationship ............. 44

Table 3 - Summary of Stepwise Regression Analysis for Variables
Predicting Participation in the Relationship ................... 46

Table 4 - Mean Provider’s Assessment of Relationship Scores
by APNCU Category ................................... 47

Table 5 - Descriptive Statistics for Psychosocial Characteristics
of Support Recipients .................................. 47

Table E1 - Summary of Adequacy of Prenatal Care Utilization Data ............... 77

viii

LIST OF FIGURES
Figure 1 - King’s conceptual framework: Dynamic interacting systems ............. 14

Figure 2 - Conceptualization of the support relationship within
King’s interacting systems framework .................... 16

ix

INTRODUCTION

Pregnancy is a signiﬁcant life cycle transition, comprising extensive physiological,
psychological, and social changes (Friedman, 1992; Thompson, 1990). Adaptation in
roles, expectations, demands, and social relationships is required. Such transition periods
are typically associated with increased stress, which has been shown to have adverse
effects on both physical and psychological health (Cobb, 1976; Cohen & Williamson,
1988; Affonso et al., 1991). Although research ﬁndings have been equivocal (Istvan,
1986; Lobel, 1994), maternal stress during pregnancy has been associated with increased
incidence of preterm delivery, low birth weight, and maternal psychological distress
(Lobel, Dunkel-Schetter, & Scrimshaw, 1992; Newton & Hunt, 1984; Norbeck & Tilden,
1983; Wadwa, Sandman, Porto, Dunkel-Schetter, & Garite, 1993; Zuckerrnan, Amaro,
Bauchner, & Cabral, 1989). Pregnant women of low socioeconomic status are at greater
risk for stress-mediated effects on their pregnancy because they face chronic everyday
stressors associated with poverty (Hoffman & Hatch, 1996; Makosky, 1982; Olds et al.,
1997; Turner, Wheaton, & Lloyd, 1995). The stressful life conditions of this population
have been associated with increased risk for the development of depressive
symptomatology (Hall, Gurley, Sachs, & Kryscio, 1991; Hobfoll, Ritter, Laven, Hulsizer,
& Cameron, 1995; Kaplan, Roberts, Camacho, & Coyne, 1987; Seguin, Potvin, St.-Denis,
& Loiselle, 1995; Zuckerrnan et al., 1989), and are compounded by the effects of social

isolation (Belle, 1982; Hobfoll et al.; Kaplan et al.; Orr & James, 1984).

2

Social support has been shown to have a protective effect on health particularly in
times of crisis and in major developmental transitions (cf. Berkman, 1984; Cobb, 1976).
This effect is proposed to result from moderation of the stress reaction, a so-called stress-
buffering effect (Cohen & Wills, 1985; Norbeck & Tilden, 1983), whereby a person’s
perception or appraisal that support is available from signiﬁcant others reduces the
intensity of the stress response (W ethington & Kessler, 1986). Research evidence has
suggested positive associations between social support during pregnancy and the health of
both mother and infant (Collins, Dunkel-Schetter, Lobel, & Scrimshaw, 1993; Heins,
Nance, & Ferguson, 1987; Nuckolls, Cassel, & Kaplan, 1972; Oakley, Rajan, & Grant,
1990; Poland, Giblin, Waller, & Hankin, 1992; Rothberg & Lits, 1991; Unger &
Wandersman, 1985).

An intervention model for the provision of social support, which has attracted the
attention of policymakers, involves the use of lay community volunteers to provide social
support during pregnancy and early parenting through a one-to-one caring relationship
(Gottlieb, 1988). Following this intervention model, indigenous women are trained to
provide social support in the home environment, in a nonhierarchical relationship that
naturally respects the values, beliefs, realities, and cultural norms of the client (Lapierre,
Perreault, & Goulet, 1995). The present study focused on such an intervention, examining
the support relationship between trained volunteer mothers ﬁom the community (support
providers) and at-risk pregnant women (support recipients) participating in the Mothers
Offering Mothers Support (MOMS) Program. The MOMS program was initiated as a

social support intervention to provide a one-to-one caring relationship for pregnant

3

women at risk for preterm delivery or delivery of a low birth weight infant by virtue of
medical or socioeconomic risk factors (Roman, Lindsay, & Moore, 1997). Support was
provided by a volunteer veteran mother who shared similar life circumstances with the
pregnant woman and had had a similar experience of at-risk pregnancy. The purpose of
this study was to describe the support provider’s assessment of the support relationship,
and to investigate associations between the provider’s assessment of the relationship and
selected psychosocial characteristics of the support recipient, as well as the recipient’s
participation in the relationship and in prenatal care. The perspectives of the provider and
the recipient relative to relationship assessment were also compared.
Statement of the Problem

Most studies evaluating social support interventions of this type have focused on such
outcomes as reduced incidence of low birth weight or preterm infants (Heins et al., 1987;
Julnes, Konefal, Pindur, & Kim, 1994; Poland et al., 1992; Spencer, Thomas, & Morris,
1989) or the mother’s participation in prenatal care (Heins et al.; Julnes et al.; Poland et
al.). The results of these studies have been nondeﬁnitive. What is lacking is empirical
research on the support relationship itself, attempting to uncover what is at the core of a
positive helping relationship and to identify the psychosocial characteristics of women
most likely to participate in and beneﬁt from interventions of this type.

Support relationships are inﬂuenced by many variables, variables within each of the
participants as well as variables of the relationship and its environmental context, including
speciﬁc stressors (Dunkel-Schetter, Blasband, Feinstein, & Herbert, 1992). Most of the

social support research has been approached from the perspective of the support recipient

4
(Dunkel-Schetter et al., 1992; House & Kahn, 1985). “As a result, we know almost

nothing about the perceptions of the provider or the degree of congruence between the
two actors’ perceptions, yet degree of congruity has important implications for the quality
and the effects of support, as well as for the probability that it will continue” (Shumaker &
Brownell, 1984, p. 18-19). By looking at the relationship from the perspective of the
support provider, this study attempted to ﬁll a gap in the social support literature.

The present study, conducted through a secondary analysis of data, addressed the
following questions:

1) What is the support provider’s assessment of the support relationship, globally and
speciﬁcally in terms of contacting, communicating with, and helping the recipient mother?

2) Is there a positive correlation between the provider’s assessment and the recipient’s
assessment of the support relationship?

3) Does the provider’s assessment of the support relationship predict the support
recipient’s participation in the support relationship?

4) Is adequacy of prenatal care for the recipient mother associated with the provider’s
assessment of the support relationship?

5) Is there an association between the recipient mother’s psychosocial characteristics of
perceived social support, perceived stress, and depression and the provider’s assessment
of the support relationship?

The support relationship between an indigenous lay support provider and an at-risk
pregnant woman was the key to the intervention model in the present study. The more that

support relationship is understood and related to relevant psychosocial variables in the

5

target population, the more knowledgable primary care providers can be in implementing
and facilitating social support enhancement in diverse settings. This type of intervention
holds promise for use particularly in primary care settings in economically disadvantaged
communities, where the beneﬁts Of providing outreach and social support through home
visiting have been recognized as complementary to traditional prenatal care, but where
limited ﬁnancial and professional resources are available for the provision of such services
(Halpem & Larner, 1987; Julnes et al., 1994; Klerrnan, 1990). The identiﬁcation and
training of indigenous support providers and the supervision and support of their work,
along with identiﬁcation of pregnant women who could beneﬁt from such a social support
relationship, would be included in the role of the advanced practice nurse (APN) as
empowerer and change agent.
Conceptual Deﬁnitions

Assessment of the Support Relationship

The focus of the present study was the assessment of the support relationship by the
support provider in that relationship. The support relationship which was assessed has not
been conceptually deﬁned as such in the literature. Gottlieb (1981) acknowledged it,
however, when he referred to “the interpersonal processes which may lie at the heart of
social support” (p. 205). It is essentially a therapeutic or helping relationship, in this case
involving a lay person in the helper role. Kanfer and Goldstein (1991) speciﬁed four
elements that distinguish a helping relationship ﬁ'om other interpersonal interactions: it is
unilateral, in that it focuses on the needs and problems of only one of the participants, the

client or recipient; it is systematic, in that there is a speciﬁed purpose or therapeutic goal;

6

it is formal in its intentionality, which includes training of the helper and informed consent
by the recipient; and it is time-limited according to the guidelines of the intervention. A
positive helping relationship is characterized by feelings of liking, respect, and trust
between provider and recipient (Goldstein & Higginbotham, 1991). The relationship is
enhanced when the individuals share a common culture and language, have similar
backgrounds, values, and attitudes, and have mutual interests and experiences (Giblin,
1989; Goldstein & Higginbotham). These similarities give the support provider an
empathic understanding of the recipient’s world and her perspective of her diﬁiculties and
the barriers she must overcome (Cohen & McKay, 1983). A positive relationship will be
evidenced in openness and communication in interaction (Goldstein & Higginbotham). On
the other hand, if interaction generates feelings of rejection, lack of self-worth, or
powerlessness in either participant, it will be avoided, resulting in failure of the
relationship (Chalmers, 1992). For this study, the support relationship was deﬁned as an
interactive interpersonal process between two individuals who share a common
background and culture, which has as its goal the provision of social support to one of the
participants, the support recipient, by the other, a lay support provider.

The social support that is provided in supportive interactions is referred to as received
or enacted support (Barrera, 1986), and is classiﬁed under three categories based on the
conceptualization of social support by House (1981): emotional support (caring and
esteem), tangible or instrumental support (tangible goods and services), and informational
support (advice and guidance) (Collins et al., 1993; Cronenwett, 1985; Dunkel-Schetter,

Folkman, & Lazarus, 1987; Gottlieb, 1978; Sarason, Sarason, & Pierce, 1990; Shumaker

7
& Brownell, 1984; Unger & Wandersman, 1985). These categories of support deﬁne the

resources that are actually provided in supportive interactions and comprise the functional
dimensions of social support (Cohen & Wills, 1985). In the intervention under study here,
emotional support was provided through listening and the development of a caring
relationship, focusing on the strengths of the support recipient; instrumental support
consisted of giving tangible assistance with such needs as transportation and child care;
and informational support involved sharing accurate information about pregnancy, birth,
and community resources, as well as modeling positive parenting (Roman et al., 1997). In
layman’s terminology, the provision of support resources is most often identiﬁed as
“helping”, which will be the conceptual term used in this study.

The recipient’s sense of being supported, however, derives not so much from what is
done by the support provider per se, but from what the provider’s behavior or manner
signiﬁes to the recipient about her level of involvement and engagement in the relationship
(Pearlin, Lieberman, Menaghan, & Mullan, 1981; Sarason et al., 1990). Cobb (1976), in
his classic work, deﬁned social support as “information leading the subject to believe that
he is cared for and loved...esteemed and valued...[and] belongs to a network of
communication and mutual obligation” (p. 300). To establish a positive helping
relationship, the support provider must in some way be able to communicate such
information to the support recipient.

The response of the recipient to support provision is equally important in supportive
interactions. An accepting response by the recipient to the caring and concern that the

provider invests in the relationship signals the recipient’s joint commitment to the support

8

process. The support recipient must enable the support process to proceed by opening the
way for the support provider to contact her, by engaging in communication, and by
sharing responsibility for her health. The assessment of the support relationship was
deﬁned, for this study, as each participant’s subjective appraisal of the degree of
engagement in relationship within the interpersonal dyad, as evidenced in contact,
communication, and the giving or receiving of help.
Participation in the Support Relationship

With the development of a positive support relationship, the support provider
essentially becomes a member of the recipient’s social support network, within the
speciﬁed time and purpose limits of the intervention (Thompson, 1990). The support
network is the structural dimension of social support, referring to the web of connections
between an individual and signiﬁcant others in her environment (Berkman, 1984; Mercer
& Ferketich, 1988). Social networks operate under distinctive cultural blueprints which
dictate their norms related to helping, including their patterns of help-seeking and the
meanings that support takes on within their context (Gottlieb, 1988). Indigenous helpers
such as those in the intervention under study, by virtue of their similar life experiences and
personal characteristics, are especially suited to become meaningful sources of support to
persons within their natural social networks (Gottlieb).

Measureable features Of support networks include size, composition (kin or nonkin),
density (patterns of interconnectedness), accessibility, frequency of contact, and durability
over time (Berkman, 1984; Cronenwett, 1985; Cutrona, 1986; Sarason et al., 1990; Unger

& Wandersman, 1985). Frequency of contact between network members is an index of

9
accessibility within their relationship (Cutrona, 1986), signaling their degree of Openness

to each other. Participation in the support relationship was deﬁned, for this study, as
engagement in the relationship through contact between support provider and support
recipient. Although there is nothing in contact itself which would indicate the quality of
the contact, contact is essential to the process of relationship formation and development.
Psychosocigl Chaﬂcteristics

The interactional view of social support presented by Sarason et al. (1990) holds that
“social support reﬂects the needs, responses, and perceptions of relationship participants
and their mutual inﬂuence” (p. 5). That is to say, the personal chacteristics of both
relationship participants, as well as their environmental situation, inﬂuence their ability to
engage in interaction that is supportive (Shumaker & Brownell, 1984). For this secondary
analysis, measures of three selected psychosocial characteristics of the support recipient
were examined for their association to relationship assessment: perceived social support,
perceived stress, and depression.

Perceived Social Support. Perceived social support is the dimension of social support
that has been most consistently related to health outcomes (Kessler & McLeod, 1985;
Mercer & Ferketich, 1988; Wethington & Kessler, 1986). It is referred to by Gottlieb
(1988) as “a psychological sense of support” (p. 36). Social support researchers have
identiﬁed and measured two distinct dimensions of perceived support: a person’s sense
(perception) that help will be available if and when it is needed, and a person’s subjective
appraisal of adequacy of and satisfaction with available support (Barrera, 1986; Cutrona,

1986; Jacobson & Frye, 1991; Sarason et al., 1990; Schaefer, Coyne, & Lazarus, 1981).

10
Perceived social support, for this study, was conceptualized as the extent to which an

individual feels that her needs for help from signiﬁcant others are and will continue to be
satisﬁed. The social support that is perceived to be available has been shown to be more
important than received support in mitigating the negative eﬂ‘ects of life event stressors
(Wethington & Kessler, 1986), through its effect on the appraisal of stressful situations.
Perceived Stress. Stress is commonly deﬁned as an imbalance between demands or
stressors and available coping resources (Cohen, Kamarck, & Merrnelstein, 1983; Wilcox
& Vemberg, 1985). The majority of studies of stress use objective major life event
measures to indicate level of stress (Cohen & Wills, 1985), although daily hassles, the
chronic, distressing demands of everyday life, have been more strongly associated with
stress-related symptomatology (Hall, 1990; Kanner, Coyne, Schaefer, & Lazarus, 1981).
Neither major life events nor chronic daily hassles, however, cause stress in and of
themselves (Cohen & Williamson, 1988). Stress is proposed to result, rather, from an
individual’s perception of events or situations as being harmﬁrl, challenging, or
threatening, coupled with her appraisal that her ability to control and cope with the event
is compromised (Lazarus, DeLongis, Folkman, & Gruen, 1985; Walker, 1989). Cohen &
Williamson deﬁned perceived stress as “the perceived degree to which environmental
demands exceed abilities to cope” (p. 37). As a global perception of recent stressors,
perceived stress should reﬂect the combined effects of major life events and chronic daily
stressors, as well as the assessment of availability of support and coping resources (Cohen

et al., 1983). For this study, perceived stress was deﬁned as the subjective appraisal of the

11

degree to which life is out of control or overloaded by stressors, such that coping is
compromised (W adhwa et al., 1993).

Depression. Depressive symptoms during pregnancy have been associated with high
levels of life event stress (Zuckerman et al., 1989), chronic stress, and inadequate social
support (Seguin et al., 1995). In studies of pregnant women of low socioeconomic status,
rates of self-reported depressive symptomatology as high as 47% have been reported
(Seguin et al.). Depressive symptomatology refers to symptoms of current depressed
mood, including feelings of helplessness, hopelessness, and guilt, loss of appetite, and
sleep disturbance, as reported by the person experiencing the symptoms on a self-report
measure (Radloff, 1977; Zuckerrnan et al.). Although these same symptoms are reported
in clinically depressed persons, the diagnosis of clinical depression requires a structured
psychiatric interview. Studies have shown only limited agreement between self-report
measures of depressive symptomatology and the actual clinical diagnosis of depression
(Alfonso et al., 1991; Holcomb, Stone, Lustman, Gavard, & Mostello, 1996). For this
study, depression was deﬁned as the self-reported assessment of the prevalence of
depressive symptoms being experienced within the past week (Comstock & Helsing,
1976), and is an indicator of risk for clinical depression.

Adequacyof Prenatal Care

 

Adequacy of prenatal care is a realistic therapeutic goal for all pregnant women.
Adequate prenatal care has been associated with signiﬁcant improvement in infant birth
weight and gestational age distributions (Alexander & Comely, 1987; Alexander &

Korenbrot, 1995; Kotelchuck, 1994b; Murray & Bernﬁeld, 1988). Empirical measures of

12

the adequacy of prenatal care are most often quantitative indices based on month of
pregnancy in which care is initiated and total number of prenatal visits, adjusted for length
of gestation (Alexander & Comely, 1987; Kotelchuck, 1994a).

Many factors inﬂuence the adequacy of the prenatal care a pregnant woman receives.
The signiﬁcant factor for this study was the support recipient’s participation in prenatal
care, which was conceptualized as a positive health behavior on her part, reﬂecting her
belief in the beneﬁts of such care for herself and her unborn child and her motivation to
seek that care (Alexander & Comely, 1987; Balcazar, Aoyama, & Cai, 1991). The
recipient’s participation in care is represented by two components of adequacy of prenatal
care indices, the month in which she begins care and the total number of visits she makes.
An index which differentiates these two dimensions of participation in care is Kotelchuck’s
(1994a) Adequacy of Prenatal Care Utilization (APNCU) Index. For this study, adequacy
of prenatal care was deﬁned as the support recipient’s participation in prenatal care both
by making an initial prenatal care visit and by presenting herself regularly for subsequent
prenatal care appointments. It is important to note that this deﬁnition of adequacy of
prenatal care does not account for barriers that may prevent the support recipient from
seeking care or from continuing in care. Furthermore, the qualitative aspects of the
prenatal care she receives, including its content, clinical adequacy, and cultural
appropriateness, are not addressed by this measure of adequacy and may have a signiﬁcant
inﬂuence both on her participation in care and on pregnancy outcomes (Korenbrot,
Simpson, & Phibbs, 1994). Adequacy of prenatal care, by this deﬁnition, simply indicates

the support recipient’s exposure to prenatal care by her own initiative.

13

To provide an overview linking the concepts presented here, both support provider and
support recipient form an assessment of their relationship. These assessments are based
upon the helping behaviors of the support provider and the response of the support
recipient, through her participation in the support relationship by way of contact and
communication. The assessments reﬂect both participants’ degree of engagement in the
relationship. The assessments may be inﬂuenced by the psychosocial characteristics of
perceived social support, perceived stress, and depression in the support recipient.
Furthermore, the degree of engagement in the support relationship may have an effect on
adequacy of prenatal care for the support recipient. The conceptual deﬁnitions for the
study variables provide the foundation for the theoretical framework.

Theoretical Framework

The conceptual framework underlying the present study is King’s (1981) framework of
dynamic interacting systems, which provides “a way of understanding human beings as
individuals interacting with other individuals within a variety of environments and
inﬂuenced by perceptions, roles, past experiences, and concrete situations” (p. viii). King
presents each human being as a unique open system (personal system) in continuous
interaction both with other unique human beings (interpersonal systems) and with larger
organized groups, communities, and systems within the total environment (social systems).
These open systems (Figure 1) have permeable boundaries, permitting a reciprocal
interchange of information, energy, and substance through interaction. Interaction is
deﬁned as a dynamic interpersonal process between personal systems, with each system

inﬂuencing and being inﬂuenced by the other (Daubenmire & King, 1973). Each

14

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Figure 1. King’s conceptual framework: dynamic interacting systems.
From Toward a theog for nursing (p. 20) by I.M. King, 1971, New York: John
Wiley & Sons. Copyright 1971 by John Wiley & Sons.

15

interpersonal interaction is shaped by a complex set of variables: by the personal
characteristics and perceptions of each participant, as well as by environmental,
situational, and social system variables (King, 1992). Through interpersonal interactions,
individuals establish relationship with one another (Frey, 1989).

For this study, the support recipient, a pregnant woman participating in the MOMS
program, was the central personal system (See Figure 2). The interpersonal system is
conceptualized as the social support network for the support recipient. The support
provider, a trained veteran mother, is shown in the model as a distinct personal system
within the social support network. The interpersonal interaction between support recipient
and support provider, conceptualized as the support relationship, was the focus of the
study. Their interaction required “mutual presence” (King, 1981, p. 85), which is
evidenced as contact and communication. Communication, the exchange and
interpretation of information within an interaction, is essential to the interaction process
(King, 1968). “The way in which each person perceives the communication will determine
the response to the other person” (King, 1981, p. 84).

Perception is a primary concept in King’s (1981) ﬁamework. Perception exists within
the personal system and is “each human being’s representation of reality...related to past
experiences, to concept of self, to biological inheritance, to educational background, and
to socioeconomic groups” (p.20). The information that an individual takes in from the
environment through the senses is organized and interpreted, based on past experiences
and present needs and values, and then transformed into that person’s unique perception.

Both support provider and support recipient in this study bring to their relationship

16

Health Care System

/———_———__———-————_—_—-\

Social Support Network \
(’Support Provider ‘\
l 0 demographics I

\ 0 assessment of relationship I
\ ________ /

\

\

\

\
I Support Recipient :
I - demographics I
I - assessment of support relationship Participation
I - perceived social support, perceived in support
| stress, depression relationship
I l
I
|
I

------- Participation in
prenatal care

  

Social Support
“helping”

    

’_—-————-———-————————-—-—_—-

Figure 2. Conceptualization of the support relationship within King’s interacting systems

framework. Adapted from Figure 1.

Support Relationship

\-———-—-——-_-—__—-————_—————--—————’

17

unique perspectives or world views (King, 1968), which are their perceptions as shaped by
such personal demographic characteristics as age, ethnic background, education, and
socioeconomic status, shown in Figure 2 within their personal systems. The fact that they
are paired for the intervention on the basis Of similar life experiences and cultural
backgrounds makes it more likely that their fundamental perceptions will be congruent. As
they interact, and based on their individual processing of what is communicated within
their interaction, each forms a unique perception of their relationship. This perception is
conceptualized as the assessment of the support relationship within their personal systems
(Figure 2).

Perception inﬂuences human interaction through its effect on a person’s actions (King,
1981). “Behavior is an expression of an individual’s perception” (King, 1968, p. 28), and,
as such, behavior conveys a message. For this study, participation in the support
relationship and participation in prenatal care were identiﬁed as desirable behaviors on the
part of the support recipient. Arrows proceeding from the recipient’s personal system in
Figure 2 indicate participation in the support relationship within the interpersonal system
and participation in prenatal care within the social system. The recipient’s assessment of
the support relationship will, theoretically, inﬂuence her willingness to continue her
participation in that relationship. It is hypothesized that that assessment will also inﬂuence
her participation in prenatal care as the social system extension of the support relationship.
Participation in prenatal care is a factor in attaining adequacy of prenatal care. These
behaviors on the part of the support recipient convey information to the support provider,

communicating the recipient’s degree of engagement in the support relationship.

18
The support provider, similarly, has behaviors that ﬂow from her perceptions. The goal

of the support relationship is the provision of social support to the support recipient.
Social support, conceptualized in this study as helping, is shown in Figure 2 as the arrow
proceeding from the interpersonal system into the personal system of the support
recipient. The provider’s assessment of the support relationship will, theoretically,
inﬂuence her provision of helping behaviors, which will in turn inﬂuence the recipient’s
perception of being helped (Dunkel-Schetter et al., 1992).

Perception may be altered by intense emotional states that are capable of distorting an
individual’s intake and processing of information (King, 1981). King views stress as
inherent in the interaction of individuals with their environment. Events (stressors) that
occur in a person’s life are perceived as positive or negative, beneﬁcial or harmful, and
that perception determines the person’s response to them. An individual perceiving a
disproportionate amount of stress may close in, making personal system boundaries less
permeable and thus limiting interaction (King). Perceived social support, perceived stress,
and depression are psychosocial characteristics of the support recipient (Figure 2) that
have the potential to affect the support relationship through their effect on the perception
and interactive behavior of the support recipient. The support recipient who feels
unsupported, stressed, and/or depressed may be either more or less receptive to support
that is available, and may also, based on her level of responsiveness, affect the probability
that others will behave in supportive ways toward her (Cutrona, 1986). These

characteristics of the support recipient will therefore, theoretically, inﬂuence

19

communication, relationship formation, and the assessment of the support relationship by
both provider and recipient.
Review of Literature

A review was undertaken of empirical studies that included as variables the key
concepts for this study. Findings from those studies having relevance to the research
questions for this study will be reported under the following headings: (a) lay health
worker social support interventions during pregnancy, (b) evaluation of support
relationships by relationship participants, (c) social support as related to adequacy of
prenatal care, and (d) psychosocial characteristics of individuals as related to interaction.
Critique and implications of the ﬁndings for this study will be presented at the end of each
section.
Lag Health Worker Socgrl Support Interventions during Pregrma

The purpose of this part of the review was to examine what has been studied thus far in
relation to lay social support interventions during pregnancy. Four studies were found in
the literature that evaluated the impact of programs in which social support was offered to
pregnant women by lay support providers (Heins et al., 1987; Julnes et al., 1994; Poland
et al., 1992; Spencer et al., 1989). In all four studies, the support intervention was
targeted to women at risk for poor pregnancy outcome, speciﬁcally adolescents (Heins et
al.; Julnes et al.), minorities (Julnes et al.; Poland et al.), low income women (Heins et al.;
Julnes et al.; Poland et al.; Spencer et al.), and women with a history of poor pregnancy
outcome (Spencer et al.). The support providers were women with cultural and economic

backgrounds similar to the women they helped, who lived in the target community and

20

received special training to implement the intervention, with the exception that Spencer et
al. described the support providers as “employed on the basis of personality and general
life experience”, with “no formal qualiﬁcations in the health or social services” (p. 282).
For each study, a comparison group which did not receive the intervention was utilized;
however, only Spencer et al. employed a prospective randomized controlled trial.

The primary focus of each of the reviewed studies was to Show evidence of an effect of
the support intervention on birth outcomes: birth weight and/or gestational age of the
infant. The results, however, were nondeﬁnitive. Spencer et al. (1989), with outcome data
available for 1227 women, found no signiﬁcant inﬂuence of the intervention on mean birth
weight, on the proportion of low birth weight infants, or on gestational age in the
comparison groups. Heins et al. (1987) found signiﬁcantly fewer low birth weight infants
among adolescent primigravidas who comprised the intervention group; and Poland et al.
(1992) found a signiﬁcantly higher mean birth weight for the intervention group, as
compared to the matched comparison group. Julnes et al. (1994) obtained comparable
infant birth weights for pregnant women receiving social support from a resource mother
and those receiving prenatal care from a multidisciplinary clinic-based program.
Roghmann (1985) cautions that to look at these objective health indicators as the only
legitimate outcomes for the evaluation of one-to-one care-giving relationships may be
misdirected, particularly in light of the complex psychosocial and socioeconomic factors
operative in these high-risk populations.

Heins et al. (1987), Poland et al. (1992), and Julnes et al. (1994) also looked at the

effects of the social support intervention on the mothers’ participation in prenatal care. All

21

three studies found improved participation in prenatal care in the intervention group, as
evidenced by signiﬁcantly earlier entry into care (Julnes et al.), a signiﬁcant increase in the
number of prenatal visits (Poland et al.), and signiﬁcantly fewer women with inadequate
prenatal care, based on broad public health indices (Heins et al.). Poland et al. noted a
direct positive association between the number of kept prenatal appointments and the
intensity of contact within the support intervention.

Study design was a signiﬁcant limitation in the four studies reviewed. Although
Spencer et al. (1989) used a prospective randomized controlled trial, only 271 of the 655
women randomized to the support intervention group accepted the family worker’s
support. Outcome data for the intervention group, however, were based on infant birth
weight and gestational age for all women who received the offer of a family worker, not
just those who accepted the offer. The designs for the other three studies were: (1)
retrospective case/control, with matching based on Vital Records and Health Statistics
data (Heins et al., 1987); (2) case comparison, with random assignment to the intervention
group and retrospective selection of a matched comparison group (Poland et al., 1992);
and (3) non-experimental, with analysis based on data for all women involved in the two
comparison programs who gave birth within a given 12-month period (Julnes et al.). All
four studies were affected by selection bias, as receipt of the intervention was dependent
upon willingness of the pregnant woman to receive support from a lay provider, even with
randomization. Participation in the intervention could then be interpreted as an indication
of pre-existing motivational advantage in the pregnant woman, which is particularly of

consequence in looking at participation in prenatal care as an outcome.

22
Evaluation of Support Relationships by Relationship Participants

As the primary purpose of the present study was to describe the lay support provider’s
assessment of the support relationship, it was important to review other studies that have
undertaken an evaluation of support relationships by relationship participants. In none of
the studies of lay support provision reviewed in the previous section (Heins et al., 1987;
Julnes et al., 1994; Poland et al., 1992; Spencer et al., 1989) was any reference made to
the process of relationship formation between lay support provider and the pregnant
woman who was being helped or to evaluation of this relationship. The value of
indigenousness and cultural identiﬁcation was highlighted (Heins et al., 1987; Julnes et al.,
1994; Poland et al., 1992), but not empirically tested. The only concrete operationalization
of the support intervention occurred in Poland et al., with intervention deﬁned as a
minimum of three contacts (face-to-face or by phone) between support provider and
recipient.

Two studies were found in which participants in a helping relationship involving nurses
evaluated their experience in the relationship, one coming ﬁ'om the perspective of the
nurse, the other from the perspective of the person being helped. Chalmers (1992), in a
qualitative study of the work of experienced health visitors (British nurses with particular
training in community health), used a grounded theory design to ascertain how the health
visitors conceptualized their practice and evaluated their interventions. Findings from the
study were that health visiting involves mutual interaction to which both health visitor and
client bring their own needs or goals. The interaction is a complex process in which each

party both gives and receives. Both the degree to which the health visitor identiﬁes the

23

client’s needs and gives the appropriate support, and the degree to which the client
receives that support and participates in ﬁlrther interaction determine the effectiveness Of
the intervention.

A study in which social support was provided by nurse midwives to women with a
previous history of delivering a low birthweight infant (Oaldey et al., 1990) used a mailed
post-partum questionnaire to obtain the mothers’ evaluation of the rrridwives’ support.
Individual questionnaire items were not reported. The authors reported only that the most
important aspect of helping identiﬁed was “listening” and that the majority of the
respondents (94%) considered the midwife support either very or quite helpful.

A gap exists in the social support literature relative to assessment of support
relationships by relationship participants. The Chalmers (1992) study contributes empirical
support to the theoretical framework presented for the current study. But much remains to
be learned about volunteer helping relationships from the people who are involved in
them. The aim of the present study was to address that gap.

Social Support related to Adequacy of Prenatal Care

Lia-Hoagberg et al. (1990) found evidence that support or encouragement ﬁ'om others,
speciﬁcally partner, family, ﬁiends, and/or professional caregivers, was a motivator to
obtaining prenatal care among low-income women in a multi-ethnic sample. Other studies
have pointed to a positive association between social support and (l) health-promoting
self-care behaviors in adult populations (Muhlenkamp & Sayles, 1986) and (2) Obtaining
adequate prenatal care among pregnant women (Higgins, Murray, & Williams, 1994). A

study by Pascoe, Milbum, and Haynes (1990) identiﬁed informal word of mouth referral

24
to care, referred to by the authors as informal network support, as a factor in ﬁrst

trimester initiation of prenatal care among unmarried women enrolling for care at a public
health prenatal clinic; however, a scale measure of social support in that same study was
not signiﬁcantly related to early entry into care. A study of prenatal care use by women
delivering at an inner-city university hospital (Passannante, Espenshade, & Weiss, 1994)
obtained a signiﬁcant relationship between receipt of adequate prenatal care and
participation in a special program providing support and education during pregnancy.

These ﬁndings, in addition to the ﬁndings cited earlier in which three social support
interventions were related to improved participation in prenatal care (Heins et al., 1987;
Julnes et al., 1994; Poland et al., 1992), would support the hypothesis that a positive
support relationship in this present study would be associated with improved participation
in prenatal care on the part of the support recipient. It is important to note, however, that
none of the reviewed studies constituted a rigorous experimental design to test this
association. All of the women included in the studies had presented for prenatal care,
which assumes some degree of self-motivation on their part. Furthermore, comparability
of studies is limited by diversity of conceptualization and measurement of social support
and of adequacy of prenatal care indices.
Psychosocial Chmcteristics of Individuals rﬂed to Interaction

If psychosocial characteristics of relationship participants have the potential to affect
the relationship through their effect on participants’ perceptions and interactive behavior,
as the theoretical model proposes, it is important to look for research evidence of this

effect. Exploration of the relationship between depression and interpersonal interaction has

25

been fairly extensive. Most studies have involved contrived situations: 1) subjects talking
by phone with targets with high self-rated depressive symptomatology drawn from a
mental health outpatient population (Coyne, 1976; King & Heller, 1984); 2) subjects
talking with depressed targets, again by self-rating, face-to-face (Strack & Coyne, 1983);
or 3) subjects talking face-to-face with a confederate enacting the depressed role
(N otarius & Herrick, 1988; Stephens, Hokanson, & Welker, 1987). Following the
conversation, subjects responded to questionnaires measuring their reactions. The results
of Coyne’s (1976) classic study, cast for participants as a study of the acquaintance
process, indicated that subjects who had interacted by telephone with depressed
outpatients were signiﬁcantly more depressed, hostile, and anxious following the
conversation than those who had talked to either nondepressed outpatients or to
nondepressed controls. In addition, these subjects were signiﬁcantly less willing to interact
with the depressed individuals again. These ﬁndings were conﬁrmed in the study by Strack
and Coyne, but not in the replication of Coyne’s study by King and Heller. However, the
rejection of ﬁrrther interaction effect was conﬁrmed by the ﬁndings in 9 of 10 studies of
depression and social interaction reviewed by Gurtman (1986); the induction of depressed,
hostile, or anxious mood in the subject was conﬁrmed by 5 of 7 studies in Gurtman’s
review.

A recent study by Nezlek, Irnbrie, and Shean (1994) focused on the naturally occurring
social interactions of a nonclirrical population deemed at risk for depression based on
scores above the critical threshhold score of 16 on the Center for Epidemiological Studies

Depression Scale (CES-D) (Radloff, 1977). Measurement of social interaction was based

26

on standardized interaction diary recordings describing the everyday social interactions of
depressed and nondepressed subjects, with entries made at least once daily for 17 days.
The results indicated that the social interactions of people classiﬁed as at risk for
depression were less rewarding in quality as compared with the interactions of persons
scoring below 16 on the CBS-D. These results, in conjunction with the ﬁndings of
previous research, led the authors to suggest that “...disturbed interpersonal relationships
are hallmarks of depression” (Nezlek et al., p. 1109).

Two studies looked at interaction with a depressed target from the perspective of a
subject in a helping role (Notarius & Herrick, 1988; Stephens et al., 1987). Notarius and
Herrick found that subjects who used supportive listening in interacting with a confederate
enacting a depressed role, as compared with those who tried to give advice or cheer up
the person, displayed signiﬁcantly less negative mood induction and were less rejecting of
the depressed target. In the Stephens et al. study, although “helper” subjects who
interacted with depressed, as compared with normal, confederates did have a more
negative view of their target and were more rejecting of him or her, no signiﬁcant
induction of negative mood in the helper was demonstrated.

Some of the researchers Obtained post-interaction questionnaire data from both
subjects and targets (Coyne, 1976; Strack & Coyne, 1983; King & Heller, [partial data],
1984). The studies employing confederate methodology, of course, presented the
reactions of subjects only (Notarius & Herrick, 1988; Stephens et al., 1987), as did Nezlek
et al. (1994), using the interaction diary. In an interactional model, investigating both

perspectives of the same interaction improves validity, for “within a given situation,

27

rejection is a product of the source, target, and the interplay between them” (Gurtman,
1986, p. 100). In keeping with an interactional model, the present study compared the
relationship assessments of both participants in the support relationship.

The implications of these interaction studies in relation to the development of an
interpersonal relationship with a depressed person are important for this study.
Nevertheless, it is notable that none of the reviewed studies examined the response to
depressed targets in the context Of an ongoing relationship; rather, with the exception of
the Nezlek et al. (1994) study, they studied brief interactions between strangers. Empirical
studies relating perceived stress and perceived social support to interaction were not found
by this author. The present study was an attempt to ﬁll this gap by demonstrating a
relationship between these psychosocial characteristics and the support provider’s
assessment of the relationship.

In summary, the literature related to social support interventions during pregnancy
involving lay volunteers has focused on measurable outcomes such as low birth weight,
preterm delivery, and participation in prenatal care, but studies have not been rigorous in
design and results have not been deﬁnitive. Qualities of the volunteer support relationship
and its meaning and value to the participants have not been researched. There is also
limited empirical evidence on the role that psychosocial characteristics Of the participants
play in the ability to form and maintain these helping relationships. This study contributes
to the knowledge base by describing the lay support provider’s assessment of the support
relationship, by looking at contact between provider and recipient as a measure of

engagement in the relationship, and by relating the relationship assessment to psychosocial

28

characteristics of perceived support, perceived stress, and depression in the support
recipient.
Methods

The primary data from which this study derived were generated from an exploratory
study (primary study) of the pilot of the MOMS Program, a social support intervention for
at-risk pregnant women initiated by a large metropolitan health system in the Midwest, in
collaboration with a state university, in April, 1993 (Roman et al., 1997). The sample for
the primary study consisted of 179 MOMS Program participants who delivered before
January 1, 1995 (Roman et al.). There was no randomization or comparison group for the
primary study. Women were enrolled in the program at the time of their ﬁrst prenatal care
contact, which occurred anywhere ﬁom the ﬁrst to into the third trimester of pregnancy.
The women received maternal and infant support services from enrollment through their
infant’s ﬁrst year of life.

Support services were provided through a case management model by a nurse-
managed community health advisor team consisting of a registered nurse, paid
paraprofessional health advocates, and volunteer veteran mothers (support providers).
Veteran mothers were recruited from the target communities through advertisements in
neighborhood and ethnic newspapers, ﬂyers in local grocery stores and laundromats, and
presentations to church and school groups. Eligibility criteria included: (a) having had a
positive parenting experience, per self-report of the mother during a personal interview
with the program coordinator; (b) a negative criminal history check; and (c) age of at least

21. Volunteers younger than 21 were included only if they showed evidence of exceptional

29

personal maturity. Preference was given to volunteers who had personally experienced a
high-risk pregnancy. Volunteers participated in twenty hours of intensive training in
preparation for their role as support providers, with additional monthly inservices provided
throughout their time of service. They were paired with enrollees on the basis of
geographic proximity, family size, life experience, interests, and ethnicity, where possible,
to provide one-to-one social support through a caring relationship. Child care and
transportation costs were provided for the volunteers, to facilitate the participation of
economically disadvantaged mothers.

The support provided to the at-risk pregnant women was of three types: emotional
support, (provided through listening and the development of a caring relationship,
focusing on the strengths of the support recipient); instrumental support, (which consisted
of giving tangible assistance with such needs as transportation and child care); and
informational support, (involving the sharing of accurate information about pregnancy,
birth, and community resources, and modeling positive parenting) (Roman et al., 1997).
The nature and degree of the intervention varied with the needs of the support recipient,
which could range from needing help with child care or information on labor and delivery
to dealing with substance abuse or domestic violence. The goal for the support providers
was to make contact with their recipient mother at least weekly during the prenatal period.

All contacts with support recipients were documented with reference to type (face-to-
face or phone) and purpose (needs identiﬁed, referrals made, and type of support given)
on monthly activity reports by the volunteer support providers. No documented validation

of these reports was available. Nurse team coordinators and team paraprofessionals,

30

however, also had contact with each support recipient and were responsible for overseeing
and supporting the volunteers in their work. Team paraprofessionals collected data from
MOMS Program enrollees at the time of their enrollment in the study and again at 34 to
36 weeks’ gestation.
Study Design

The current study was a descriptive correlational secondary analysis of data. The intent
of the study was to describe the support provider’s assessment of the support relationship
and to explore associations between this assessment and three psychosocial characteristics
of the support recipient, perceived social support, perceived stress, and depression, as well
as its relationship to the support recipient’s participation in the support relationship and in
prenatal care. The relationship assessments of provider and recipient were also correlated,
for the limited sample available.
Sam le

The sample consisted of 64 dyads composed of MOMS Program participants (support
recipients) with their paired support providers. A dyad was included in the sample under
the condition that an Assessment of the Support Relationship had been completed by the
support provider early (at approximately one month) in the relationship. The 54 support
providers, 13 of whom provided support to more than one program participant, had been
recruited ﬁom target communities and active in the MOMS Program between April, 1993,
and December, 1994. MOMS Program participants had been drawn from among pregnant
women presenting for care at one of four prenatal clinics in a Midwest metropolitan area.

These clinics were located in inner city neighborhoods and served predominantly low

31

socioeconomic and minority populations. Program participation was open to all on the
basis of their voluntary consent, but was limited by the number of support providers
available for matching. Some women were speciﬁcally referred to the program by clinic
social workers, but enrollment remained voluntary.
Instruments

Assessment of the Support Relationship Scale. An assessment measure was developed
by Roman (see Appendix A), an investigator for the primary study, to document
perceptions of the support relationship by both support providers and support recipients.
The measure has two comparable versions, one adapted for use by the support provider,
one by the support recipient. Four items from the 9-item assessment tool were selected to
comprise an Assessment of the Support Relationship summated rating scale for this study
(see Appendix A). The selected items included a global assessment of the relationship,
items on ease of making contact and ease of communicating within the relationship, and an
item assessing whether help was being provided within the relationship. The items not
selected for inclusion in the assessment of relationship scale for this study included three
items in which respondents were asked to indicate an explanation when they perceived
that there was difficulty in the relationship, an item assessing whether the relationship
participants like each other, and an open response item regarding what help was needed
from the program. Selection of items was based on the conceptual and theoretical
formulation of the assessment of the support relationship concept for this study. The four
items selected for use in the Assessment of the Support Relationship scale were scored on

a 5-point Likert scale ranging ﬁom 1 (poor, difﬁcult, or never) to 5 (ggeat, easy. or all of

32

the time). There has been no previous reliability or validity testing for this instniment. A
Cronbach’s alpha of .84 was obtained for the present study. The relationship assessment
scale has not been used in any other setting.

Measure of Perceived Support (MPS). Perceived social support was measured using an

 

adaptation of a scale developed by McMillan (unpublished data, 1976), and used by
Wandersman, Wandersman, and Kahn (1980). The original 4-item scale measured a
person’s perception of having sufficient close ﬁiends to provide help and act as
conﬁdante. Mercer and Ferketich (1988) adapted the original scale, creating the 6-item
MPS used in the primary study for this data set (see Appendix A). Examples of scale items
include “I feel loved” and “There are people who I can count on to help if I need them”.
The items are rated on a 5-point scale ranging from 1 (never true) to 5 (almost always
t_r_u_e_:). The one negative item (#3) is reverse scored. Mercer and Ferketich (1988) reported
alpha reliabilities of .71 to .80 for the four groups in their study, a sample consisting of
predominantly white, married, middle and upper socioeconomic class pregnant women and
their mates, one group of which was hospitalized for a high-risk pregnancy-related
condition. Cronbach’s alpha of .71 was obtained for the current sample.

Perceived Stress Sgale (PS§). The PSS is a 14-item measure designed to assess the
degree to which respondents perceived their total life circumstances in the last month to be
stressful, as in uncontrollable, unpredictable, or overloading (Cohen etal., 1983, p. 387)
(see Appendix A). Responses to scale items range on a 5-point scale from 1 (M) to 5
(vegy often). Sample questions include “How Often have you been upset because of

something that happened unexpectedly?” and “How often have you felt that things were

33

going your way?” The 7 positive items (#4, 5, 6, 7, 9, 10, 13) are reverse scored. Cohen et
al. reported coeﬁicient alpha reliabilities of .84 to .86 in samples of college students and
adult participants in a community smoking cessation program. They reported test-retest
reliabilities of .85 at 2 days and .55 at 6 weeks. Internal consistency of .86 was reported in
a study sample of predominantly white, married, college-educated mothers of infants
(Walker, 1989). The scale has been shown to have a small to moderate correlation with
life event measures of stress (Cohen et al.), to be highly correlated with a measure of daily
hassles (Wadhwa et al., 1993), and to be substantially correlated with measures of physical
symptomatology (Cohen et a1; Cohen & Williamson, 1988). Although this scale was highly
correlated with the CES-D in two samples of college students (.65 and .76), Cohen et al.
demonstrated that the two scales independently predicted physical symptomatology and
concluded that the PSS was measuring a different construct. Cronbach’s alpha of .72 was
obtained for the present study.

Center for Epidenriologjcal Studies-Depression Scale. Depressive symptomatology was
measured using the Center for Epidemiological Studies-Depression Scale (CES-D)
(Radloff, 1977). This 20-item self-report measure asks subjects to indicate on a 4-point
scale how Often they felt or behaved as described during the past week, from 0 (w
none of the time) to 3 (most 0311 of the time), measuring current levels of depressed
mood. The four positive items (#4, 8, 12, 16) are reverse scored. Internal consistency of
the scale has been consistently high among all population groups, with reported
Cronbach’s alphas of .85 to .90 (Hall, 1990; Hall et al., 1991; Radloﬁ). Validity of the

CES-D is based on moderate correlations of the measure with other self-report depression

34

scales and on the consistently high CES-D scores among those with diagnosed clinical
depression (Radloff). The CES-D has been shown to be a valid measure of depressed
mood during pregnancy, in spite of the overlap of the somatic items on the scale with
common symptoms of pregnancy (Zuckerman et al., 1989), and has been used to measure
depressive symptomatology among populations of low-income mothers (Hall et al., 1991;
Orr & James, 1984; Zuckerman et a1, 1989). A standard cut-off score of 16 or greater has
been used to identify persons at risk for depression (Radloff). Cronbach’s alpha of .79 was
obtained for the present study.
Operationﬂeﬁnitions of Variables

Assessment of the Support Relationship. The assessment of the support relationship
between a MOMS Program participant and her matched support provider was based on
subjective responses by relationship participants to the four items comprising the
Assessment of the Support Relationship scale. The provider’s assessment was obtained
early in the relationship, approximately one month after initiation. This early assessment
had the advantage of providing a prospective view of the relationship, with potentially
more predictive power. The recipient’s assessment was obtained at 34 to 36 weeks’
gestation. The summated score for the four items was used as the measure of the
assessment. Possible scores ranged from 4 to 20, with a higher score indicating a more
positive assessment of the relationship.

ﬂirticipation in the Support R_elationship. Participation in the support relationship was
operationalized as the total number of face-to-face visits plus phone contacts between the

support provider and the support recipient from the initiation of the relationship to the

35

time of delivery. This number was based on records of these visits and phone contacts as
entered by the support provider on monthly activity reports.

Adequg of Prenatal Care. For this study, adequacy of prenatal care was deﬁned
quantitatively based on Kotelchuck’s (1994a) Adequacy of Prenatal Care Utilization
(APNCU) Index, which differentiates two dimensions of prenatal care utilization: (a)
adequacy of initiation of prenatal care, and (b) adequacy of care utilization after
enrollment or adequacy of received services, based on American College of Obstetricians
and Gynecologists standards (ACOG, 1989), and adjusted for gestational age at both
initiation of care and at delivery. These two dimensions are then combined to create a
single summary index. The resulting summary categories of prenatal care utilization as
employed for this study are: (a) inadequate, deﬁned as initiation of care after the 4th
month or less than 50% of recommended visits; (b) intermediate, deﬁned as initiation of
care by the 4th month and 50-79% of recommended visits; (c) adequate, deﬁned as
initiation of care by the 4th month and 80-109% of recommended visits; and (d) adequate
plus, deﬁned as initiation of care by the 4th month and 110% of recommended visits
(Kotelchuck, 1994a). Month of initiation of prenatal care was based on the month of
gestation at the time of the support recipient’s ﬁrst visit to the prenatal clinic, as recorded
on the MOMS Program enrollment form. Number of prenatal visits was obtained ﬁ'om the
participant’s prenatal clinic records and included only the visits which had been scheduled
for the purpose of routine prenatal assessment by a primary care provider. Gestational age

at birth was deﬁned as the number of completed weeks of pregnancy, based on the date of

36

the woman’s last menstrual period, and was obtained in the primary study from the
woman’s hospital obstetric record.

Psychosocial Chagcteristics of the Support Recipient. The three psychosocial
characteristics of the support recipient considered in this study were perceived social
support, perceived stress, and depression. These characteristics were measured using
instruments completed by the support recipient at the time of enrollment in the MOMS
Program. Perceived social support was measured using the MPS, as adapted by Mercer
and Ferketich (1988). Possible scores ranged from 6 to 30. Perceived social support was
treated as a continuous variable with lower scores indicating lower perceived support.
Perceived stress was measured using the PSS (Cohen et al., 1983), and was also treated as
a continuous variable, with high scores indicating higher levels of perceived stress, with a
possible score range of 14 to 70. The CES-D scale was used as the measure of depression,
with summary scores ranging from 0 to 60 (Radloff, 1977). A score of 16 or greater was
interpreted as indicating a high level of depressive symptoms, based on general population
samples in which at least 80% of respondents have scored below 16 (Comstock &
Helsing, 1976; Radloﬂ). For this study, depression was treated as a dichotomous variable,
as recommended by Nezlek et al. (1994). Those support recipients scoring l6or more on
the CES-D were classiﬁed as having high depressive symptomatology; those scoring
below 16 were classiﬁed as having low depressive symptoms.

Procedures
Variables of relevance to this study were provided in coded form on a disk by the

investigators for the primary study. (See Appendix B for Procedures for Primary Study).

37
Data Analysis

Descriptive statistics were calculated for all study variables, including ﬁ'equencies,
means, and standard deviations, where appropriate, on both total scores and speciﬁc scale
components. For all analyses, the alpha level of signiﬁcance was set at .05.

Demographics. Descriptive statistics were computed for the demographic
characteristics of support providers and support recipients, including age, ethnicity, marital
status, educational level, employment status, and insurance status, and were reported by
percentages, means, and standard deviations as appropriate.

Research Question 1. Descriptive statistics were used to describe the support
provider’s assessment of the support relationship by Assessment of the Support
Relationship scale items: global assessment, contacting, communicating, and helping. The
Assessment of the Support Relationship scale score was computed through summation of
the four items, with mean and standard deviation reported.

Research Question 2. Pearson product-moment correlation was utilized to designate
the magnitude of the relationship between Assessment of the Support Relationship scale
scores for the provider and the recipient within each dyad.

Research Question 3. Stepwise linear regression was used for this analysis, with
provider Assessment of the Support Relationship score as the predictor variable and
participation in the relationship as the criterion variable. Length of the support relationship
(computed as weeks from date of enrollment in the MOMS Program to date of delivery)
was entered ﬁrst in the regression analysis to control for the effect on the number of

contacts occurring between support provider and support recipient. The sample included

38

only dyads for whom length of relationship was at least 4 weeks, based on the
understanding that support providers made their relationship assessments approximately
one month after initiation of the relationship (Roman, personal communication).

Research Question 4. Analysis was done using one-way AN OVA, with the four
APNCU Index categories of adequacy of prenatal care as the categorical variables and
provider’s assessment of the support relationship score as the dependent variable.

Research Question 5. Pearson correlations were used to examine the associations
between the provider’s assessment of the support relationship score and both the
perceived social support and perceived stress scale scores of the recipient. Depression
scale scores were dichotomized and exanrined using AN OVA, with depression as the
categorical variable and provider assessment of the support relationship score as the
dependent variable.
Assumptions

The accuracy of the data contained in the primary data set, including collection,
recording, and coding, were assumed for this secondary analysis. The accuracy of the
information on methods and procedures for data collection that were provided was also
assumed. Although no attempt was made in the present study to Objectify or quantify the
supportive skills of the support providers, there was the underlying assumption that they
had the capability to provide social support, based on their indigenousness and their

training.

39

Limitations

The present study was a descriptive, correlational secondary analysis of data. For the
primary study, there was no random assignment to the support intervention, and no
control group was used for comparison purposes. Participants enrolled in the MOMS
Program through a self-selection process and thus could be said to have possessed
preexisting diﬁ‘erences in motivation and need, which may have inﬂuenced the variables
under study. These limitations were inherent from the primary study and preclude the
suggestion of any causal relationships between the variables under study or generalizability
of the ﬁndings of the present study to other populations.

The sample for the present study was limited by a low rate of return on relationship
assessments by support providers, with only 64 of 179 potential assessments available for
analysis. Absence of assessments for the other 115 dyads leaves a substantial gap in the
data. The return rate by support recipients was even lower, with only 11 of 179 program
participants completing relationship assessments. These missing assessments placed a
great limitation on what could be learned from the study.

The Assessment of the Support Relationship scale, the focal measure for this study,
was an untested instrument, without previous use or established reliability and validity.
The limitations of using an untested instrument include the potential that the scale is not a
true or comprehensive measure of relationship assessment. The fact that the scale is
comprised of only 4 items adds substance to that possibility; however, the four items are
relevant to relationship assessment as presented in the theoretical model for this study and

therefore, the scale was considered a beginning measure of the concept. A further

40

limitation of using an untested instrument is that it is not appropriate for the population
being studied. Response bias is another limitation inherent in a scale of this design. In
reference to the scale item on helping in the relationship, it is important to note that no
attempt was made in the present study to identify the content of the help being provided,
that is, the support provider’s meaning of helping or the support recipient’s meaning of
being helped.

There are additional psychosocial characteristics of the support recipient that could
potentially inﬂuence relationship formation. The selection of perceived social support,
perceived stress, and depression for this study was based on the conceptual and theoretical
formulations presented here, as well as the review of the literature. It is important to note
in reference to depression that the CES-D is a measure of depressive symptomatology
only and is not to be interpreted as a clinically diagnostic measure.

There was also a limitation inherent in determining the correlation between assessment
of the support relationship scores obtained at different times in the relationship, at one
month for the support provider and at 34 to 36 weeks’ gestation for the support recipient,
as this places the provider’s assessment in a more predictive rather than comparative role.
Protection of Human Subjects

Approval to proceed with this study was obtained from the University Committee on
Research Involving Human Subjects (UCRIHS) prior to accessing any of the data (see
Appendix C). Approval for the primary study was obtained ﬁ'om UCRIHS and the
appropriate hospital Human Subjects Review Board (Roman, personal communication).

Written approval to access the primary data set for this secondary analysis was obtained

41
from the primary investigators for the primary study (see Appendix D). Aggregate data

were reported in coded form, identifying support providers and recipients by identiﬁcation
number only. Exceptions to this involved demographic data on support providers and the
support recipients’ assessments of the support relationship. These data were entered by
the investigator for the present study from original self-report Volunteer Proﬁle forms and
recipient assessment of relationship forms, respectively; however support providers and
recipients were again identiﬁed by number only.
Results

Sample Description

Sixty-four support provider/support recipient dyads comprised the sample for the
present study. The 64 support recipients were the subset of the 179 women enrolled in the
primary study for whom an Assessment of the Support Relationship was completed by
their respective support provider at approximately one month into the relationship. Thus,
only dyads for whom the length of the support relationship was at least 4 weeks were
included in the sample. Providing support to these 64 support recipients were a total of 54
support providers, 13 of whom worked with more than one program participant.
Demographic data for support recipients were obtained from an enrollment form
completed by participants upon entry into the MOMS Program. Demographic data were
available from Volunteer Proﬁle forms for 42 of the 54 support prOviders. Demographics
for both support recipients and support providers are reported in Table 1. In general,
support providers were older than support recipients, with the age of support recipients

ranging from 15 to 36 M = 22.2; SD = 4.6) and that of support providers ranging from

42
Table 1

Frequency and Percent of Demographic Characteristics of Support Recipients and Support

 

 

Providers.
Support Recipients Support Providers
Characteristics p = 64 p = 42
Number (%) Number (%)
Race/ethnicity
White 30 (46.9) 18 (45.0)
Aﬁican American 23 (35.9) 15 (37.5)
Hispanic 9 (14.1) 6 (15.0)
Native American 2 ( 3.1) 1 ( 2.5)
Marital Status
Never married 50 (78.1) --
Single -- 16 (40.0)
Married 6 ( 9.4) 16 (40.0)
Separated 2 ( 3.1) 4 (10.0)
Divorced 5 ( 7.8) 4 (10.0)
Educational Level (years)
Less than 12 28 (43.8) 5 (12.2)
12 or more 33 (51.6) 36 (87.8)
Insurance Status
Medicaid/pending 54 (84.4) --
Private 5 ( 7.8) --
Employment Status
Presently Employed 22 (34.4) 23 (54.7)
Not Employed 37 (57.8) 13 (31.0)
Seeking Employment 5 ( 7.8) --
Student -- 6 (14.3)

 

Note. Dashes indicate that comparative data was not available.

43
18 to 58 (1\_/I = 31.7; S_D = 8.1). Support providers were also more likely than support

recipients to be married, to have a higher level of education, and to be employed. A
demographic comparison of the 64 support recipients in this study to the 179 enrollees in
the primary study, using t-test and Chi-square statistics, showed no signiﬁcant differences;
with respect to employment, however, the difference approached signiﬁcance (p = .052),
with more of the support recipients in this smaller sample being employed.

Results Related to Research Question_s

Resparch Question 1: What is the support provider’s assessment of the support
relationship, globally and speciﬁcally in terms of contacting, communicating with, and
helping the recipient mother?

Descriptive statistics for the support provider’s assessment of the support relationship
are outlined by item in Table 2. The Assessment of the Support Relationship scale, a
summated score of the 4 items in Table 2, had scores ranging from 4 to 20, with a mean
score of 15.0 (S_D = 3.8), indicating positive relationship assessment.

Research Question 2: Is there a positive correlation between the provider’s assessment
and the recipient’s assessment of the support relationship?

There were only 11 dyads in the study sample for which an assessment of the support
relationship was available both from the support provider at approximately one month into
the relationship and from the support recipient at 34 to 36 weeks’ gestation. The mean
Assessment of the Support Relationship scale score for these 11 support recipients was
15.0 (SD = 4.4). The mean relationship assessment score for their 11 support providers

was 15.4 (S_D = 4.3). The signiﬁcant positive correlation between provider and recipient

44
assessments (g = .89, df = 9, p < .001) indicates a high level of agreement within the dyad

relative to the relationship assessment.

Table 2

Support Provider’s Assessment of the Support Relationship (N = 64)

 

 

1 2 3 4 5
Assessment (poor, difﬁcult, (great, easy
Score never) all the time)
n (%) a (%) n (%) a (%) a (%)
Global
Assessment 3 (4.7) 5 (7.8) 5 (7.8) 34 (53.1) 17 (26.6)
Contacting 8 (12.5) 12 (18.8) 7 (10.9) 15 (23.4) 22 (34.4)
Communicating 2 (3.1) 8 (12.5) 2 (3.1) 18 (28.1) 34 (53.1)
Helping 2 (3.1) 4 (6.3) 22 (34.4) 31 (48.4) 547.8)

 

Research Question 3: Does the provider’s assessment of the support relationship predict
the recipient’s participation in the support relationship?

This question was analyzed for 49 dyads. One study dyad with a relationship length of
59 weeks was eliminated on the basis of being greater than the 40 week duration of a
normal pregnancy. Data to calculate length of relationship were missing for an additional
13 cases. The length of the support relationship for the 49 dyads ranged from 4.6 to 33.9

weeks, with a mean of 20.7 weeks (_S_1_)_ = 8.6).

45

Participation in the support relationship, operationalized as the total number of
contacts between support provider and support recipient over the length of the
relationship, ranged from 1 to 70; however, the dyad with 70 contacts was eliminated
from the analysis as an outlier. For 49 dyads, a mean of 13.8 contacts (S_D = 12.4) was
computed. For 51% of the dyads, the total number of contacts was 10 or less. The
majority of contacts occurred by phone, the mean number of phone contacts being 8.9
($2 = 9.6). The mean number of home visits was 3.4 (S_D = 3.8) with 22% of the sample
reporting one home visit and 16% reporting none.

Stepwise linear regression analysis of provider’s assessment of the support relationship
as predictor variable to participation in the relationship, with length of the relationship
entered on step one as the control variable, revealed that length Of the relationship
accounted for 10.1% of the variance in participation in the relationship, R_2 = .10, E (1, 47)
= 5.3, p = .03. When provider’s assessment of the relationship was added to the equation,
18.1% of the variance was accounted for, E = .18, E (2, 46) = 5.08, p = .010. Thus the
provider’s assessment explained 7.9% of the variation in participation in the relationship,
making a small but signiﬁcant contribution beyond what was explained by length of the
relationship alone (see Table 3).

Research Question 4: Is adequacy of prenatal care for the recipient mother associated
with the provider’s assessment of the support relationship?

Descriptive statistics on adequacy of prenatal care for support recipients are reported
by APNCU Index categories (Kotelchuck, 1994a) in Table E1 (Appendix E).

Approximately one-third of the study dyads could not be assigned an APNCU Index

46
Table 3

Summary of Stepwise Regression Analysis for Vaﬂables

Predicting Participation in the Relation_ship (n = 42

 

 

 

Variable _B _SE_B 13g
Provider’s Assessment 0.96 0.46 028*
Length of Relationship 0.43 0.19 0.30*

*p < .05.

category because the necessary information for computing the APNCU category was not
available, speciﬁcally, the month of entry into prenatal care. Kotelchuck (1994a) used birth
certiﬁcate data for his analysis, but month of initiation of prenatal care for this study was
obtained ﬁom the MOMS Program enrollment form by self-report of the support
recipient, veriﬁed by the team paraprofessional.

Recipients entered prenatal care at a mean of 2.9 months (S_D = 1.8) and had an
average of 10.1 prenatal visits (S_D = 5.4). Mean provider assessment of relationship
scores by APNCU category are reported in Table 4. One-way ANOVA showed no
signiﬁcant main effects between the four APNCU categories with respect to the provider’s
assessment Of the support relationship, E (3, 36) = .88, p = .46.

Research Question 5: Is there an association between the recipient mother’s
psychosocial characteristics of perceived social support, perceived stress, and depression
and the provider’s assessment of the support relationship?

Descriptive statistics on psychosocial characteristics of support recipients, including

perceived stress, perceived social support, and depression, are reported in Table 5. There

47
Table 4

Mean Provider’s Assessment of Relationship Scores bv APNCU Category (II = 40)

 

 

 

Summary Adequacy of Assessment Score
Prenatal Care Utilization
Category 2 (%) M (S_D)
Inadequate 9 (22.5) 13.3 (4.8)
Intermediate 9 (22.5) 15.4 (4.8)
Adequate 16 (40.0) 15.5 (2.9)
Adequate Plus 6 (15.0) 16.3 (3.8)

 

were no signiﬁcant differences in means for these variables between the current study
sample and the sample for the larger primary study. Correlations between the provider’s
assessment of the relationship and psychosocial characteristics of the support recipient
were not signiﬁcant: perceived social support (1 = -.16; df = 57; p = .22); perceived stress

(1 = .01; df= 60; p = .92); and depression (1 = -.11; df= 59; p = .39).

Table 5

Descriptive Statistics for Psychosocial Clﬂacteristics of Support Recipients (n = 64)

 

 

Psychosocial Characteristic M _SQ Range
Perceived Social Support 14.9 5.0 7 to 28
Perceived Stress 28.5 6.3 15 to 43

Depression 22.1 10.1 4 to 48

 

48
Dichotirnization of CES-D scores showed that 15 (23.4%) of the support recipients

had CES-D scores of 15 or less, indicating low depressive symptomatology, while 46
(71.9%) had scores of 16 or greater, indicative of a high level of depressive
symptomatology. The mean provider assessment of the relationship score for support
recipients with low CES-D scores was 16.1 (SD = 3.4), while the mean assessment score
for recipients with CES-D scores of 16 or greater was 14.6 (S_D = 3.9). One-way ANOVA
of level of depressive symptomatology by provider’s assessment of the support
relationship showed no signiﬁcant effects, 1;“ (1, 59) = 1.78, p_= .19.
Discussion

The purpose of this study was to add to the knowledge base pertaining to social
support interventions during pregnancy involving lay support providers. The study
described the support provider’s assessment of the support relationship and investigated
associations between that assessment and key psychosocial variables and behaviors of the
support recipient. The fact that the provider’s assessment of the support relationship was
completed for only 64 of 179 subjects in the primary study greatly limited the sample size
for the current study. This low rate of completion (36%) could be attributed to a low
priority placed on obtaining this assessment by the primary investigators, as it was not a
key variable in the primary study. It may also be explained as a common concern in
working with volunteers, the problem of ensuring compliance in record-keeping and
documentation of work (Poland et al., 1992). This problem was also evidenced in the 78%
completion rate on demographic proﬁles by the 54 volunteer support providers in this

study sample.

49

Support Recipients

Demographics. The 64 support recipients in the study sample were comparable to

 

those in the primary study sample with respect to demographics and psychosocial
characteristics. These support recipients were also similar to those in other studies
involving at-risk pregnant women in urban settings with respect to age and the high
percentage on public insurance, with an educational level of less than 12 years, and not
employed (Hobfoll et al., 1995; Holcomb et al., 1996; McLaughlin et al., 1992; Poland et
al., 1992; Zuckerman et al., 1989). Although data were difﬁcult to compare with respect
to marital status because of variation in categories of measurement for this variable across
studies, it would appear that fewer of the support recipients in the current study were
married (9.4%, as opposed to 16 % in Poland et al. and 37% in Holcomb et al.); however,
the group of never married subjects (a = 50; 78%) was not subdivided according to
percentage living without a partner, as in other studies (3 7% in Hobfoll et al., N = 192;
38% in Poland et al., N = 111).

Psychosocial Chmcteristics. It was also important to compare the support recipients
in this study to other study samples with respect to the psychosocial characteristics of
perceived social support, perceived stress, and depression. The Measure of Perceived
Support (MPS) used in the primary study for this secondary analysis has not been widely
used, so little comparative data was available. On a possible score range of 6 to 30, with
lower scores indicating lower perceived support, the mean score for the present study
sample was 14.9 (SD = 5.0). Mercer and Ferketich (1988) obtained mean MPS scores of

24.3 (E = 3.8) and 23.6 (SD = 4.0) for pregnant women of high and low obstetric risk,

50

respectively, but the women in their sample were predominantly married, well-educated,
and of higher economic status than the women in the current study. Warren (1997) also
reported high levels of perceived social support, studying a sample of middle class Aﬁican
American women demographically similar to those in the Mercer and Ferketich study, but
employing a different measure of perceived support, the Personal Resource Questionaire
Part II (Brandt & Weinert, 1981). Zachariah (1994), studying a very small sample of low-
income mothers in a parenting program (a = 7), reported mean MPS scores of 14.9 (pre-

intervention) and 18.4 (post-intervention; SDs not reported). Comparison of scores

 

suggests that lower levels of perceived support may exist among women who are not
married, have less formal education, and are of low socioeconomic status.

A review of studies that employed the Perceived Stress Scale (PS S) used in the present
study showed mean scores of 23.2 ($2 = 7.3) and 23.7 (S_D = 7.8) in samples of college
students (Cohen et al., 1983), 25.0 (S_D = 8.0) in a smoking-cessation group sample
(Cohen et al.), 19.6 (S_D = 7.5) in a large Harris survey sample (Cohen & Williamson,
1988), and 25.0 (S_D = 8.0) in a sample of predominantly white, married, well-educated
mothers of young children (Walker, 1989). The mean of 28.5 (SD = 6.3) in the present
study is indicative of higher levels of perceived stress among these support recipients.
These higher levels are consistent with the ﬁndings of Cohen and Williamson (1988) that
showed signiﬁcantly higher levels of perceived stress among female respondents of
younger age, lower household income, less education, and single/never married status. In
contrast, Lobel and Dunkel-Schetter (1990) reported low levels of perceived stress, a

mean of 5.0 (S_D_ = 3.0) on a scale range of 0 to 20 using a 5-item version of the PSS, in a

51

sample of socioeconomically disadvantaged pregnant women who were predominantly
Spanish and living with a partner. They attributed this low perceived stress to habituation
and lowered expectations in the face of chronic exposure to diﬂicult conditions. The
preponderance of evidence, however, points to a substantial link between low social
status, difﬁcult life circumstances, the experience of chronic stress, and high perceived
stress, which has been associated with poor mental health in the lives of low-income
women such as those who were support recipients in this study (Makosky, 1982; Belle,
1990; Turner et al., 1995).

High rates of depression are consistently reported for samples of low income pregnant
women. Hobfoll et al. (1995) reported a prenatal incidence of major or minor clinical
depression of 41.7% in their sample, based on Research Diagnostic Criteria. Seguin et al.
(1995), using the Beck Depression Inventory (BDI), a self-report measure of depressive
symptomatology that is widely used in pregnancy (Beck, 1996), with a standard cut-off
score of 10 to indicate signiﬁcant levels of depressive symptoms, reported an incidence of
depressive symptomatology of 46.9%. Holcomb et al. (1996), using both the BDI and
diagnostic interview criteria to screen for depression in pregnancy, obtained an 11%
prevalence of diagnosed clinical depression, with 43% of the sample scoring 10 or greater
on the BDI. Zuckerman et a1. (1989) used the CBS-D as the measure of depressive
symptomatology, as used in the present study, and reported a mean score of 18.6 (S_ =
10.8). The sample in Zuckerman et al. had a higher percentage of Black subjects than in
the current study, but was otherwise comparable. Scores on the CES-D in studies of low-

income mothers of young children showed means of 17.8 (S1; = 11.7) (Hall, Williams, &

52
Greenberg, 1985); 19.2 (S_D = 10.3) (Hall et al., 1991); and 12.7 (S_D = 9.8) (Hall, 1990);

with 48%, 60%, and 49% of subjects scoring sixteen or greater, respectively, indicative of
high depressive symptomatology (Radloff, 1977). The mean CES-D score of 22.1 (S_D =
10.1) for the current study is considerably higher than in the cited comparison studies, as
is the percentage (75%) scoring 16 or greater.

Caution must be used in interpreting CES-D scores, particularly during pregnancy, as
the scale contains items relating to common physical and emotional symptoms of
pregnancy such as fatigue, lack of energy, nausea, disturbed sleep patterns, and crying
spells (Huffman, Lamour, Bryan, & Pederson, 1990). Some researchers recommended
omitting these items from the scale to avoid confounding of the assessment (Hobfoll et al.,
1995; Hoffman & Hatch, 1996), while others suggested that higher cut—off values for
signiﬁcant depressive symptoms need to be established for the pregnant population
(Holcomb et al., 1996). Zich, Attkisson, and Greenﬁeld (1990) found that, even within a
non-pregnant primary care population sample, a higher or “stringent” cut-off score of 27
was accurate in identifying 100% of those with diagnosable depression, while eliminating a
signiﬁcant number of false positives. For this study, 16 of the support recipients (26%)
scored at or above the more stringent cut-off of 27. In any event, self-report scales are not
diagnostic for depression, but rather alert the practitioner to an elevated risk for
depression within a given population and are useful as a screening tool (Holcomb et al.;
Radloff, 1977). The high CES-D scores in this study sample, in comparison to other
studies of low income pregnant women and young mothers, are such an alert and provide

a rationale for intervention, including further diagnostic evaluation and treatment

53

according to clincial practice guidelines. The social support intervention under study here
could serve as an adjunct in treatment.
Providers’ Relationship Assessments

The providers’ assessments of the support relationship, the focus of this study, tended
to be highly positive. Although the assessment form was one which could lend itself to
response bias, the occurrence of negative assessments gives support to the conclusion that
respondents felt free to be honest in their assessments. It is conceivable that the care which
was taken in the pilot study to pair support provider and recipient with respect to such
characteristics as ethnicity, life experience, number of children, and interests may have
contributed to greater compatibility and thus higher relationship assessments. It is
noteworthy that age was not a basis for pairing. Support providers ranged in age from 18
to 58. Depending upon their age with respect to that of the support recipient, some
support providers would be viewed as peer supporters, while the older ones may have
been experienced more in the category of motherly or grandmotherly supporters. This
study does not account for these potentially disparate perspectives in interpreting the
assessments of the relationship, but that would be an important factor for consideration in
ﬁlture studies.

Ninety percent of the support providers responded positively to an item assessing
whether they “liked” their support recipient, while 84% were highly positive that the
support recipient liked them. A premise of this study was that lay workers will relate well
to the targets of their support by virtue of their cultural and experiential similarities and

understanding of each other (Brooks-Gum et al., 1989). The high nonresponse rate in

54

completing the assessment form, however, on the part of both providers and recipients, is
a severe limitation of the study, as nonresponse is typically not a random process and may
have signiﬁcantly biased the results (Polit & Hungler, 1995). The richness in the data may
lie in what is missing.

In a study of volunteer helping relationships among the elderly (Morrow-Howell, Lott,
& Ozawa, 1990), 60% of the volunteers rated their helpﬁrlness to their clients at “a lot” or
“a great deal”, as did 56% of the volunteer support providers in the current study. Only
9% of the support providers indicated that they never or not often felt they were helping
their support recipients. This sense of helping, the provision of social support, is important
in the theoretical model. A support provider who does not feel she is helping her support
recipient is likely, according to the model, to have a more negative assessment of the
support relationship and helping behavior will be reduced, in a circular pattern. The
provider’s positive sense that she is helping is inﬂuenced by the recipient’s participation in
the relationship. The participation in the relationship data should, therefore, be consistent
with the positive relationship assessments of the support providers.

The highest number of negative assessments (p = 20, 31%), notably, were given in
reference to ease of contacting the recipient mother. Although the mean length of the
support relationship in weeks was 20.7 (_S_I_) = 8.6), the mean number of contacts was 13.8
(S_D = 12.4), considerably less than the intervention goal of one contact per week.
Explanations for difﬁculty in making contact included, in descending order of frequency,
no phone, does not return my calls, and never home, consistent with patterns of frequent

moves, lack of phone access, and absence of consistency in schedules for this population

55

(Barnard et al., 1988). However, as the theoretical framework postulates, contact is an
essential component of relationship formation, and, for this study, contact between
support provider and recipient, either by phone or face-to-face through home or clinic
visit, served as the operationalization of participation in the support relationship.
Communication, the other essential component of relationship formation, was evaluated
only through response on the assessment form with respect to how easy it was to talk with
the support recipient, and, for this item, 81% of the assessments were positive, compared
to 58% positive assessments on the contacting item. Again, it is important to keep in mind
that these percentages are based on a sample that is only 36% of the 179 participants in
the primary study.
Participation in the Support Relationship

The record of contacts between support provider and recipient was an instance in
which the availability of data was dependent on record-keeping accuracy and diligence on
the part of the volunteer support provider, over which there was random surveillance by
team paraprofessionals and the nurse team coordinator. Low rates of completion of
demographic and assessment of relationship forms, as already discussed, attest to the
potential for inexactitude of data here. Based on the intervention goal of at least one
contact per week, participation in the relationship, divided by number of weeks in the
relationship, was low for the dyads in this study at a mean of 0.78 visits per week (S_D_ =
.64). However, it was not low in comparison to patterns suggested by other studies.
Poland et al. (1992) set a minimum of 3 contacts to deﬁne that intervention had occurred,

and reported a mean for weighted contacts of 14.7 (SD = 12.8), with face-to-face contacts

56

scored as 3 and phone contacts scored as 2. Thus the non-weighted mean number of
contacts of 13.8 (S_D = 12.4) in the present study was considerably higher. Heins et al.
(1987) and Spencer et al. (1989) reported intervention goals of monthly visits and 1 to 2
visits per week, respectively, but did not provide data on actual completed visits. In a
study by Villar et al. (1992), 83% of the support providers made the expected 4 to 6
prenatal home visits. The support intervention in the Villar et al. study was a planned
sequence of home visits by trained professional nurses and social workers. Olds,
Henderson, Tatelbaum, and Chamberlin (1986) initiated a randomized controlled trial to
study a comprehensive program of nurse home visitation in which an average of 9 prenatal
home visits were made by professional nurses. For the present study the median number of
contacts was comparatively higher at 10, but more than 50% of the support providers
recorded fewer than 3 home visits. The effectiveness of home versus phone contacts has
not been established, however, and the potential beneﬁts of having indigenous volunteers
working with high-risk pregnant women must be weighed against the resultant informality
of the intervention, with associated difficulties in assuring that prescribed contact and
documentation expectations are met. Indeed, indigenous volunteers may be contending
with distressing life circumstances of their own which may interfere with performance
expectations, but which may enhance their ability to relate to their support recipient.
Although only 7.9% Of the variance in participation in the relationship was explained by
the provider’s assessment, the assessment was a signiﬁcant predictor of participation,

lending support to the theoretical model.

57

Participation in Prenatal Care

The extent of participation in prenatal care for the support recipients in this study, with
48.5% (p = 31) entering prenatal care by the third month and 47% (p = 30) having 10 or
more prenatal visits, resulting in only 34.4% (p = 22) having adequate or adequate plus
prenatal care utilization according to the Kotelchuck categorization (Kotelchuck, 1994a),
is less adequate than reports of prenatal care utilization in the existing literature.
Passannante et al. (1994), studying a comparable sample of low-income inner-city
pregnant women, reported that 57% of the women in their sample received adequate
prenatal care, based on a modiﬁed Kessner index (Peoples, Grimson, & Daughtry, 1984)
and using birth certiﬁcate data, and 66% initiated care in the ﬁrst trimester. Alexander and
Korenbrot (1995), citing data from over 3,500,000 live births in the US. to women of all
economic levels, reported 56% of the mothers having adequate prenatal care, with less
than 7% having inadequate or no prenatal care, again based on a modiﬁed Kessner index
(Alexander & Comely, 1987). For the present study, 14.1% (a = 9) of the support
recipients received inadequate care; however, the signiﬁcant percentage (p = 24; 37.5%)
of the Study sample for whom insufﬁcient information to calculate adequacy of care was
available should not be overlooked in interpreting these ﬁndings. Davids (1993), who
studied race and adequacy of prenatal care in low income women, reported low
percentages of the study sample having adequate or intensive care (18% for Aﬁican
American and 39% for Caucasian women), again using the adapted Kessner (Alexander &
Comely), with only 19% of African American and 26% of Caucasian women initiating

care in the ﬁrst trimester. The use of diﬁ‘erent indices of prenatal care utilization makes

58

cross-study comparison difficult; however, both the present study and Passannante et al.
(1994) showed a higher percentage of women initiating care early than Davids found,
indicative of a higher motivation to seek and participate in care on their part.

Any inﬂuence of the social support intervention in this study on support recipients’
participation in prenatal care would occur through adequacy of received services, since
there was not an outreach component of the program to effect earlier entry into prenatal
care, unless it was word of mouth referral from other support recipients. In this regard, the
advantage of the Kotelchuck APNCU Index is that adequacy of initiation of prenatal care
and adequacy of received services are considered separately. Only 4 (6.3%) of the support
recipients had inadequate received services or expected visits after initiation of care.
Kreiger, Connell, and LoGerfo (1992), however, also reported low percentages of women
with inadequate expected visits, using the received services portion of the Kotelchuck
index, ﬁom 4.5% to 13.3% in 6 different Medicaid plans not having a speciﬁc intervention
component. Passannante et al. (1994) note that this population may attain the
recommended number of prenatal visits despite later onset of care because of more
frequent visits toward the end of pregnancy associated with their high risk status, thus
skewing the results toward greater adequacy than is actually present.

Although no signiﬁcant association between levels of participation in prenatal care and
the provider’s assessment of the relationship was demonstrated, mean provider assessment
scores by APNCU category were in the expected direction, with support recipients with
more adequate participation in prenatal care having higher mean assessment scores. The

small number of subjects for each APNCU category may have been a factor in the failure

59

to demonstrate statistical signiﬁcance. Prenatal care was deﬁnitely one of the areas that
support providers addressed in their contacts with their support recipients, as veriﬁed by
entries in their contact records. It cannot be concluded from the data and analysis
presented here that the intervention did not contribute positively to this behavioral
outcome on the part of the pregnant woman. That effect could better be studied by
comparing participation in prenatal care for women receiving versus those not receiving
the intervention, as in Heins et al. (1987), Julnes et al. (1994), and Poland et al. (1992).
Kitzrnan et al. (1997), however, in a randomized controlled trial of nurse home visitation
in a sample of pregnant women comparable to the one in this study, found no effect of the
intervention on participation in prenatal care.

Relationship between Psychosocial Cha_gcteﬁstimnd Assessment

 

Based on the research evidence on depression and interaction presented in the review
of the literature for this study, it could be hypothesized that the high levels of depression
(with concomitant high levels of perceived stress and low levels of perceived social
support) among the support recipients in this study would have hindered the development
and progression of their support relationships, resulting in less positive relationship
assessments. The effects of negative stress in decreasing personal system boundary
permeability, according to King’s theoretical framework, would ﬁrrther support that
expectation. A signiﬁcant association between support recipients’ psychosocial
characteristics and relationship assessment was not obtained, however. Furthermore,
assessment scores were not signiﬁcantly diﬁ‘erent between support recipients in the high

and low depressive symptomatology groups, although the difference was at least in the

6O

expected direction. More positive relationship assessments were made for women scoring
less than 16 on the CES-D than for those scoring 16 or greater. It could be postulated that
the depressive symptomatology within this sample contributed to the support providers’
sense of helping their support recipients, thus fostering the support relationship
irrespective of the recipients’ psychological state. Futherrnore, the symptomatology of the
support recipients may have contributed to their care-seeking behavior and to heightened
receptivity on their part. An association between CES-D scores of 16 or greater and
increased use of health services has been reported in the literature (Callahan, Hui,
Nienaber, Musick, & Tierney, 1994). Zuckerman et al. (1989), on the other hand, found
no association between trimester of ﬁrst prenatal visit and mean CES-D score. The fact
that assessments for 64% of pilot study dyads are missing does not permit a deﬁnitive
statement on this question.

Although not speciﬁcally related to the study questions, the associations between the
psychosocial characteristics of the support recipients deserve comment here. As others
have noted, perception of both stress and social support is likely to be inﬂuenced by a
depressed frame of mind (Hofﬁnan & Hatch, 1996; Paarlberg et al., 1996; Seguin et al.,
1995). Conversely, high levels of stress and low levels of social support could contribute
to depressive symptoms (Hall. 1990). The high correlation between CES-D and perceived
stress in the present study (g = .68, p < .001) is consistent with the literature (Cohen et al.,
1983; Hall, Kotch, Browne, & Rayens, 1996; Seguin et al.), but suggests the possibility
that these instruments are measuring similar rather than independent constructs. High

levels of depressive symptomatology and perceived stress have been shown to be

61

associated with low levels of perceived social support, however, in an inverse relationship
(Hall et al., 1991; Paarlberg et al.). For the present study, that inverse relationship to
perceived support was not found (CES-D: [ = .49, p < .001; perceived stress: a = .55, p <
.001). A possible explanation is that the social support that was available to these support
recipients was not positive, but served to bring even more stress into their lives, as
discussed by Belle (1982).

Implications for the Advanced Practice Nurse in Primary Care

The major ﬁndings of this study were that lay support providers in the MOMS
Program who made an assessment of their social support relationship with an at-risk
pregnant woman were highly positive in their assessment, and that their assessment of the
relationship was signiﬁcant in predicting the support recipient’s participation in that
relationship. Furthermore, for a very limited sample, there was high congruence in
relationship assessments within the provider- recipient dyad. An association between
providers’ relationship assessments and levels of perceived stress, perceived social
support, and depression in the support recipients was not demonstrated.

Several implications can be suggested on the basis of these ﬁndings for the APN as
primary health care provider. Studies have shown that key social support providers for a
pregnant woman are her partner (Hobfoll et al., 1995; Norbeck & Anderson, 1989) and
her mother (N orbeck & Anderson). A high percentage of women in the low
socioeconomic population, however, are not married (78% in the present study), or may
be involved in less than positive relationships (Belle, 1982). They may also be living away

from close relatives or extended family. The APN’s thorough assessment of the pregnant

62

client should include assessment of her existing social support resources. The low
perceived social support scores of the support recipients in this sample should serve as an
alert to this action. Because life circumstances of at-risk pregnant clients tend to be
unstable, this assessment of social support resources should be on-going, up—dated at each
prenatal visit, and should be given priority equal to that placed on the assessment of
physical parameters in the pregnant client.

The preponderance of evidence for the potential beneﬁcial eﬁects of social support in
pregnancy should lead the APN to attempt to augment this resource when support
resources are low (Collins et al., 1993; Heins et al., 1987; Norbeck & Anderson, 1989;
Nuckolls et al., 1972; Oakley et al., 1990; Poland et al., 1992; Rothberg & Lits, 1991;
Unger & Wandersman, 1985). The ﬁndings from the present study suggest that social
support provision by lay volunteers has the potential for positive relationship formation
and is a viable option for the APN to consider in formulating a plan for social support
augmentation. While the number of relationship assessments completed was
disappointingly low and unsubnritted assessments may have been more negative, in 80% of
completed assessments, support providers were positive in their global rating of the
relationship. These volunteers had a positive perception of the helping relationships in
which they were involved, which, in turn, according to the theoretical model, would be
communicated to the support recipients through their interaction. The high correlation
between provider and recipient assessments serves as additional evidence in support of this
interaction model. This kind of positive interaction in the lives of both of these women is

what could make a difference for their ﬁrtures.

63

The APN in primary care should be aware of existing lay support provider resources in
the community and be open to working collaboratively with these lay providers in
delivering comprehensive care to pregnant women. The APN should be able to recognize
and appreciate their unique contribution as members of the health care team. Using
leadership skills, the APN could be instrumental in the development of social support
interventions of this type by facilitating networking between existing lay support provider
programs in other communities and key agencies within the target community.

The high levels of perceived stress and depression among the support recipients in this
study are again an alert to the APN to assess these psychosocial characteristics of the
pregnant women in their practice, and to continue to monitor them over the course of the
pregnancy. The APN is trained to empower clients in stress management, through
identifying stressors and their effects and the client’s typical coping mechanisms, and then
working with the client to develop a plan for stress management. For those clients
reporting high levels of depressive symptomatology, ﬁrrther screening to rule out a clinical
diagnosis of depression would be indicated, with initiation of appropriate treatment for
depressed clients following clinical practice guidelines.

In this study, a signiﬁcant association between the provider’s relationship assessment
and these psychosocial characteristics of the support recipient was not demonstrated,
suggesting that positive support relationships can develop in spite of high levels of
perceived stress and depression in the support recipient. This ﬁnding suggests that use of
lay volunteers for social support intervention should not have to be limited based on the

psychosocial characteristics of the recipient. In fact, the pregnant women who are often

64

the most difﬁcult for health care providers to reach may be the ones who could most
beneﬁt from a relationship with a lay support provider. The fact that lay providers are part
of the natural social support network, rather than an arm of the health care establishment,
may foster trust and openness in the support relationship that cannot be attained by the
health care provider.

A social support intervention of this nature requires ongoing evaluation by the APN
who is responsible for case management of the care of the pregnant support recipient. The
ﬁnding that a positive relationship assessment by the support provider was predictive of
the support recipient’s participation in the relationship has implications for evaluation. The
provider’s relationship assessment for this study was obtained approximately one month
into the relationship and predicted the amount of contact occurring between provider and
recipient throughout the prenatal period. Ifthe lay support provider has a positive
assessment of the relationship, this study supports the assumption that contact between
provider and recipient will be maintained over the length of the relationship. Only through
this contact between provider and recipient, that is, through participation in the
relationship, can emotional, informational, and tangible social support be enacted.
Therefore, if the provider’s relationship assessment is negative, the ﬁndings here would
lead the APN to further evaluate that relationship and possibly recommend that another
lay support provider be substituted or look for another way to provide support to that
particular client. The evaluation component is critical, and the APN is well-equipped to

conduct it.

65
Peoples-Sheps, Eﬁrd, and Miller (1989) surveyed experts in prenatal care and found

that these experts indicated that the most effective strategy for modifying prenatal care
behaviors among socially disadvantaged women was the use of peer home counselors, but
that this was also the least-used strategy in actual practice. Although the research evidence
presented here does not Show a signiﬁcant relationship between a positive relationship
assessment and improved participation in prenatal care, the trend of the results in the
expected direction holds forth promise in the face of the dismayingly low levels of
participation in prenatal care among this population. The APN should seriously consider
this type of social support intervention in evaluating strategies to address prenatal care
issues for the at-risk pregnant population.
Implications for Future Research

The present study had signiﬁcant limitations and leaves many unanswered questions
about the support relationship between a lay support provider and an at-risk pregnant
woman. Any attempt to replicate or expand upon this study should address the issues and
concerns raised in the following paragraphs. First, the development of a valid, reliable,
more comprehensive instrument for measuring relationship assessments by the relationship
participants requires more groundwork. A qualitative study using grounded theory design
(Chalmers, 1992), with personal interviews of both support providers and support
recipients, either individually or in focus groups, would be valuable in uncovering key
factors that relationship participants consider in forming their perception of this helping
relationship. How important is intensity of contact, and do certain avenues of contact

(home visit versus phone) have greater impact or inﬂuence in framing their perception of

66

the relationship than others? What are objective elements of their experience of
communication that could be measured? What is their meaning of “helping”, and how
much does this contribute to the experience and perception of relationship? What, for
them, constitutes a relationship that “works”? The value of indigenousness to relationship
formation should also be explored. A qualitative study such as this would provide a
research basis for a more inclusive and valid instrument for relationship assessment, which
could then be tested in a variety of settings.

A carefully developed and tested instrument would provide valuable information for
program assessment. Priority would have to be placed on assuring assessment completion
both by support providers and support recipients, rectifying the problem of low return
rates which limited the present study. The use of incentives could be considered, to
facilitate compliance. Obtaining relationship assessments from both provider and recipient
at key times, that is, early in the relationship and again at weeks 34 to 36 of the pregnancy,
prior to delivery, would be critical. Having two relationship assessments, made at different
times in the relationship, would provide important information on relationship
development and change over time.

The pregnant women who were support recipients in this study had high levels of
perceived stress and depressive symptomatology and low levels of perceived support.
Thus the needs of this population of women are great, and their environmental
circumstances are not easily altered. Support providers, drawn from the target
communities and with similar life circumstances, have potentially similar psychosocial

needs. Should scores on these psychosocial indices be considered in establishing eligibility

67

criteria for both support providers and support recipients? At what level of depressive
symptomatology is clinical intervention indicated? Should pregnant women who are
clinically depressed be considered eligible for a lay support intervention at all? How
intensive should provided services be, and how intensive can they realistically be under
managed care? Can lay support be as effective for these at-risk women as professional
counseling would have been, or could lay and professional interventions potentially work
synergistically? Does the intervention have “sufﬁcient” effectiveness? Further study should
follow the psychological indices of support recipients over the course of the intervention,
with measurements taken at regular intervals, to provide quantitative data relative to any
effects of the intervention on the psychological well-being of the support recipient. A
randomized controlled study of lay social support provision both with and without
professional counseling intervention versus no support augmentation could provide
valuable information with which to address the above questions.

Another critical area for ﬁrture research has to do with participation in the support
relationship. Documentation in this regard has not been rigorous, for this study as well as
in other studies of this type of intervention (Heins et al., 1987; Julnes et al., 1994; Poland
et al., 1992; Spencer et al., 1989). Is there a critical threshhold for number of contacts that
signals relationship formation or determines a successﬁrl intervention? Halpem and Lamer
(1987) emphasized the value of home visiting for meeting clients on their own turf,
presumably a less threatening environment than a clinic or health center, and one affording
an opportunity for demonstration and modeling. Is there an optimal goal for number of

prenatal home visits? Should the intervention follow a prescribed regimen, deﬁning what is

68

to be addressed at each visit? At what point would such deﬁnition detract from the
indigenous component, making the volunteers just one more system? Can number of
contacts be tied to measurable outcomes, such as participation in prenatal care or
gestational age at delivery or infant birth weight?

The whole area of prenatal care utilization as related to lay social support provision
was left in question by this study. Did some of these women enter prenatal care early
because of their high levels of stress and depressive symptomatology? Was it the
informational support of the lay volunteers or their intensity of need that kept them in
care? These questions could better be addressed by a randomized controlled trial of this
social support intervention, which the investigators for the primary study of the MOMS
Program are currently undertaking. More rigorous studies are needed to provide research
evidence upon which the APN can base a plan of care to augment social support and to
address the problems of high stress and depressive symptomatology and inadequate
prenatal care in this high-risk population.

Summary

This study described lay volunteers’ assessments of their social support relationships
with at-risk pregnant women and investigated associations between their assessments and
psychosocial characteristics and behaviors of the support recipients. The positive mean
relationship assessment scores from support providers in the present study suggest that
positive helping relationships between lay support providers and at-risk pregnant women

can develop. These positive relationship assessments occurred irrespective of high levels

69

of perceived stress and depression and low levels of perceived social support in the
support recipients.

The Assessment of the Support Relationship Scale used for the present study was an
untested instrument and can be considered only a preliminary measure of relationship
assessment. The study was further limited by low return rates on relationship assessments
by both support providers and support recipients and by the fact that relationship
assessments were not obtained from support recipients early in the relationship. A
comparison control group without social support intervention was not constituted for the
primary study. These issues should be addressed by future research on social support
relationships in the indigenous volunteer model.

The theoretical model for the study, based on King’s interacting systems, was
supported in that the provider’s relationship assessment was predictive of participation in
the relationship. Support relationships were sustained through on—going contact between
lay provider and support recipient over the prenatal period, providing opportunity for the
provision of emotional, informational, and tangible support by the indigenous volunteer.
This type of social support intervention warrants recognition by APN primary care
providers as a viable option for support augmentation for their at-risk pregnant clients.
The high levels of perceived stress and depression and low levels of social support
evidenced in the support recipients in this study should alert APNs to conduct ongoing

assessment of these psychosocial parameters in all pregnant clients.

APPENDICES

APPENDIX A

70

MOMS '0 t‘ DDDD ' DD VOI- ID“ DDDD -DD
DATE DD ' DD - DD PM '0' DDDD ~DD
PARENT-ro-PARENT PROGRAM

’3.

’5.

'7.

VOLUNTEERS ASSESSMENT OF THE SUPPORT RELATIONSHIP

For me. this support relationship is:

El Cl Cl E] El

Poor Fair Average Good Great
(1) (2) (3) (4) (5)

lfyou marked 1,2. or3. please indicatewhyyou think this is so (check all that apply).

D (I) Mothermoved C] (6) I‘mtoostreeeedlbusy

[j (2) Momerhamtourtto [j mMomet-sptooietmstetoomohrormetohsndte
[j (3) Moutersremttymendssteunoomromuewmtouttetattonshtp

[j (4) Motherhastoomahyiamllyproblemstoperticipate

 

 

Contacting yourmomis: 4. Ityoumarkedt.2.or3. hdicete why you think this is so.
Elm 0mm [3(1) Nophono
[3(2) Somewhetdiﬂicult [3(2) Neverhome
[3(3) NeIthetdtrrIouItoressy [3(3) Meeeageenotreoelved
[3(4) Somswhsrm [3(4) Ooeshottemmmyoeus
1:115)an [3(5) Other
Telkingwithyourmomis: 6. lfyoumarked1.2.or3.indicetewhyyouthinkthisisso.
Du) Difﬁcult [3(1) She'srealquiet
[j (2) Somewhatdifﬁcult [1(2) She's neveteione
1:](3) Neltherdll'hcultoreasy [3(3) Otherpeopretslkrorher
[1(4) Somwhateasy 1:](4) Sheseemsangry
D(5)Easy 1:](5)Sheseemsoeptessed
[3(6) Other

Doyoufeelyouarehelpingthismom?

Cl E] El El El
Never Not Often Sometimes Most of the time All of the time

(1) (2) (3) (4) (5)

Do you like this mom? [:1 (1) Not sure [:1 (2) Sometimes [:1 (3) Usually [:1 (4) Always

Do you think she likes you? [:1 (1) Not sure 1:] (2) Sometimes 1:] (3) Usually [j (4) Always

What do you need from the program to help you in your role as a volunteer?

MOMS '0‘ CIDDD 431:1

DATE: DD - DD - DD PM 10* DDDD -DD
PARENT-TOPARENT PROGRAM
PARTICIPANTS ASSESSMENT OF THE SUPPORT RELATIONSHIP
‘ 1. For me. this support 2. It you marked 1,2, or 3. indicate why you think
relationship is: this is so (check all that apply)
[:1 (1) Poor D (1) Volunteer moved
C] (2) Fair 1: (2) Volunteer is too stressed/busy
D (3)Average D (3) Volunteer hard to talk to
D (4) Good D (4) My problems are to much for volunteer
D (5) Great D (5) Volunteer uncomfortable with relationship
‘ 3. Contacting your volunteer is: 4. it you marked 1,2, or 3. Indicate why you think this is so.
D1) Difﬁcult D (1) No phone
D (2) Somewhat diriicuit D (2) Never home
D (3) Neither difﬁcult or easy D (3) Messages not received
D (4) Somewhat easy [I (4) Does not return my ails
CI (5) Easy D (5) Other
' 5. Talking with your volunteer is: if you marked 1,2, or 3. indicate why you think this is so.
D (1) Difﬁcult D (1) She's real quiet
D (2) Somewhat difﬁcult D (2) Doesn't understand my problems
E] (3) Neither difﬁcult or easy C] (3) She doesn't listen
1:] (4) Somewhat easy D (4) She doesn't seem interested
[I (5) Easy D (5) Other
7. Do you like this volunteer? Do you think she likes you?
[:I (1) Not sure [3 (1) Not sure
D (2) Sometimes D (2) Sometimes
D (3) Usually D (3) Usually
D (4) Always D (4) Always
' 8. DO you feel your volunteer is helping you?
C] (1) Never
D (2) Not otten
D (3) Sometimes
D (4) Most of the time
D (5) All or the time
9. What do you need from the program to help you?

71

vou .0. 13131313 -i:li:i

 

 

 

 

72

momsm DUDE-DE]
WAVE lD# [3E]

PARENT-TO-PARENT PROGRAM
MEASURE OF PERCEIVED SUPPORT

 

Almost Often Sometimes Seldom Never
Always True Tnle True True
True

 

i feel loved.

 

I am satisﬁed with the number Of close
friends i have.

 

I wish that there were more people
around with whom I might share
personal things.

 

There are people who I can count on
to help if I need them.

 

My friends are helpful.

 

I am satisﬁed with the help I get.

 

 

 

 

 

 

 

 

 

 

 

 

73

moms nor DUDE] £11]
WAVE ID# DD

PARENT -TO-PARENT PROGRAM
PERCEIVED STRESS

The questions in this scale ask you about your feelings and thoughts during the last month. In each
case. you will be asked to indicate how often In the last month you felt or thought a certain way.
Although some Of the questions are similar. there are differences between them and you should treat
each one as a separate question. The best approach is to answer each question fairly quickly.

 

Almost Some- iFairly Very
IN THE LAST MONTH Never never times often often

(I) I2) I3) (4) I5)

 

1. How often have you been upset because of something
that happened unexpectedly?

 

2. How Often have you felt that you were unable to control
the important things in your life?

 

3. How often have you felt nervous and ”stressed“?

 

4. How often have you dealt successfully with irritating life
hassles?

 

5. How often have you felt that you were effectively coping
with important changes that were occurring in your life?

 

6. How Often have you felt conﬁdent about your abiTity to
handle your personal problems?

 

7. How often have you felt that things were going your
way?

 

8. How often have you found that you could not cope with
all the things that you had to do?

 

9. How Often have you been able to control irritations in
your life?

 

10. How Often have you felt that you were on top Of things?

 

11. How Often have you been angered because of things
that happened that were outside of your control?

 

12. How often have you found yourself thinking about things
that you have to accomplish?

 

13. How often have you been able to control the way you
spend your time?

 

 

14. How Often have you felt difficulties were pﬁing up so
high that you could not overcome them?

 

 

 

 

 

 

 

APPENDIX B

74

APPENDIX B

Procedures for Primary Study

Pregnant women desiring to participate in the MOMS Program signed a consent form
explaining the support intervention, its duration, and the voluntary nature of their
participation, assuring conﬁdentiality, and authorizing use of their own and their infant’s
medical records for information relating to program evaluation. Enrollment data from
participants, including the psychosocial characteristics measures of relevance to this study,
were obtained by a team paraprofessional at the time of the enrollee’s consent to
participate in the program. All instruments were self-administered, with assistance
provided by the paraprofessional as needed. Assessment of the support relationship forms
were distributed to support providers one month after the initiation of the relationship and
to both providers and support recipients at approximately 34 to 36 weeks’ gestation. The
support providers understood that their reports would be used for program evaluation

purposes.

APPENDIX C

 

GREEN:
RESEARCH
AND
GRADUATE
STUDES

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75

APPENDIX C

UCRIHS Approval
MICHIGAN STATE

U ii I \l E I! S I 1’ Y

March 20, 1997

 

T0: Rachel F. Schiffman
A230 Life Sciences

RE: IRE“: 97-176
TITLE: SOCIAL SUPPORT PROVISION IN AT-RISK PREGNANCY BY
LAY COMMUN TY VOLUNTEERS: THE

I ASSESSMENT OF
SUPPORT RELATIONSHIP
REVISION REQUESTED: N/A
'CATEGORY: 1~E
APPROVAL DATE: 03/17/97

The university Committee on Research Involving Human Sub ects'(UCRIHS)
review of this project is complete. I am pleased to adv se that the
rights and welfare of the human subjects appear to be adequately

rotected and methods to obtain informed consent are appropriate.
Therefore, the UCRIHS approved this project and any reVisions listed
above.

RININAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u te certification. There is a
maximum of four such expedite renewals ssible. Investigators
wishing to continue a project beyond tha time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at an 0 her time during the year
send your written request to the CRIBS Chair, requesting revised
approval and referencing the project's IRB S and title. Include
in our request a description of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

enosnxls/ ,

CHANGRS: Should either of the followin arise during the course of the
work, investigators must noti UCRIHS promptly: (1) roblems
(unexpected side effects, comp aints, e c.) involving uman
subjects or I2) changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2180 or FAX (517l4 2- 171.

Sincerely,

 
  
  
   

l
id 3. Wright, Ph.
CRIHS Chair

DEﬂzbed

Carol Powers

APPENDIX D

76

APPENDIX D

Permission to Access Data

Prevention Outreach Services

Parent to Parent Program
Buttsrworth Hospital

I00 Michigan. NB - M094
Greed Rapirk, Ml 49503

 

 

May 7. 1996

Carol Powers
15861 Buchanan
West Olive. Ml 49480

Dear Carol:

We have received your proposed research questions and request to use our MOMS
data set to conduct a secondary analysis for your masters thesis. We understand that
you want to explore perceptions of the volunteers and participant's assessment of
supportive relationship with client demographic and psychosocial characteristics. client
program participation and participation in prenatal care.

Guidelines for authorship will be developed between the student and the project co-
prlncipal investlgatore. Any manuscript or presentation resulting from this thesis must
be reviewed by the co-principal investigators prior to submission.

Marcie Gebben, our research coordinator. has indicated that she has discussed with
you the availability of demographic data on the volunteer sample and whether the data
needed to assess adequacy of prenatal care is in the data set. Marcia can get this
information for you in a more timely manner. As you ﬁnalize the variables you need in
the data set. we will make this data set available to you on disc so that you can proceed
with the analysis.

We are excited about your study and look forward to working with you, Carol.

Sincerely.

W 6’34 4"“ "‘
J Lindsay. BSN, MPA Lee Anne Roman. PhD. Jose 8. Moore. MD
Program Director Research Director Medical Director
Prevention Outreach Prevention Outreach Prevention Outreach

 

fax (616) 3914305 phone (6 i 6) 391-2627

APPENDIX E

77

APPENDIX E

Table El

Summary of Adgcipacy of Prenatal Care Utilization data (N = 64)

 

 

Adequacy of Adequacy of Received Adequacy of
APNCU Category Initiation of PNC PNC Services PNC Utilization
No. (%) No. (%) No. (%)
Inadequate 3 (4.7) 4 (6.3) 9 (14.1)
Intermediate 4 (6.3) 11 (17.2) 9 (14.1)
Adequate 14 (21.9) 17 (26.6) 16 (25.0)
Adequate Plus 23 (35.9) 8 (12.5) 6 ( 9.4)
Missing 20 (31.3) 24 (37.5) 24 (37.5)

information

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