Poverty reduction and childhood opportunity moves: A randomized trial of cash transfers to low-income U.S. families with infants.

Black and Hispanic children have a higher likelihood of experiencing neighborhood poverty than white children. This study uses data from the Baby's First Years (BFY) randomized trial to examine whether an unconditional cash transfer causes families to make opportunity moves to better quality neighborhoods. We use Intent to Treat linear regression models to test whether the BFY treatment, of receiving $333/month (vs. $20/month) for three years, leads to moves to neighborhoods of greater childhood opportunity. Overall, we find no relation between the BFY treatment and neighborhood opportunity across time. However, we find effect modification by maternal baseline health. High-cash receipt among mothers with poor health at baseline corresponds with moves to neighborhoods of greater childhood opportunity.

Informal support and obligation contribute to fewer child behavior problems over time.

Objective: This study used longitudinal data from a sample of low-income mothers and their children to examine how informal support and obligation, or informal networks, contribute to children's behavior. We also tested the potential mediating role of maternal parenting stress. Background: Many studies document the importance of informal support for maternal stress and child behavior to offset the negative impact of poverty for low-income families. Evidence suggests the importance of also considering the obligations that such informal support access may impart. Method: Using data from the Welfare, Children, Families Study, a longitudinal study of diverse, low-income, urban mothers in three cities (n = 2,142), we used a parallel process latent growth curve model approach to examine how informal support and obligation contributed to maternal stress and child behavior. Results: Models indicated that mothers with healthy safety nets, including informal support and manageable obligations, had children with fewer behavior problems, and parenting stress partially accounted for the positive effects. Conclusions: Results highlight the importance of considering reciprocity norms among low-income mothers; one-sided support or obligation can be problematic for both maternal stress and child behavior problems. Implication: Results suggest the merit of empirically supported interventions to teach relationship skills and facilitate healthy relationships among low-income mothers.

Considering Health Literacy, Health Decision Making, and Health Communication in the Social Networks of Vulnerable New Mothers in Hawai'i: A Pilot Feasibility Study.

Health literacy is understudied in the context of social networks. Our pilot study goal was to consider this research gap among vulnerable, low-income mothers of minority ethnic background in the state of Hawai'i, USA. Recruitment followed a modified snowball sampling approach. First, we identified and interviewed seven mothers ("egos") in a state-sponsored home visiting program. We then sought to interview individuals whom each mother said was part of her health decision-making network ("first-level alters") and all individuals whom the first-level alters said were part of their health decision-making networks ("second-level alters"). Health literacy was self-reported using a validated item. A total of 18 people were interviewed, including all mothers (n = 7), 35% of the first-level alters (n = 7/20), and 36% of the second-level alters (n = 4/11). On average, the mothers made health decisions with 2.9 people (range: 1-6); partners/spouses and mothers/mothers-in-law were most common. One mother had low health literacy; her two first-level alters also had low health literacy. Across the full sample, the average number of people in individuals' health decision networks was 2.5 (range: 0-7); 39% of those interviewed had low health literacy. This can inform the design of future studies and successful interventions to improve health literacy.

Evaluation of a social marketing approach to healthy, home-cooked family meals for low-income mothers of young children.

Cooking is a complex behavior associated with more frequent and nutrient-dense family meals. The Cook Together, Eat Together (CTET) social marketing program used formative, process, and outcome evaluations over a 3-year period to design a program to increase fruit and vegetable intake and frequency of family meals. We used a quasi-experimental, mixed-methods design with a nonequivalent comparison group to evaluate fruit and vegetable intake and family meals. Eight focus groups of mothers in low-income families with young children revealed two predominant behavioral mediators: (i) importance of family time and (ii) desire for children to learn to cook and become self-sufficient adults. Program design was grounded in formative evaluation and organized by the four Ps of social marketing: (i) product-learning to prepare healthy meals while teaching children to cook; (ii) price-lowered by reducing barriers of food cost, kitchen clean-up, meal planning, grocery shopping; (iii) placement-in neighborhood gathering places with a "cooking social"; and (iv) promotion-flyers, newsletters, and social media. Outcome indicators were assessed pre/post intervention with questions from instruments validated for the audience. Significant changes (n = 68, p ≥ .002, Bonferroni adjustment for p = .05, Cohen's d = .50 medium effect size) were found in consumption of fruits and vegetables with an average increase of half cup each per day. CTET participation significantly increased fruits and vegetables served and eaten at family meals. A social marketing approach can help families with young children increase fruit and vegetable consumption.

Predictors of psychological distress in low-income mothers over the first postpartum year.

Up to 25% of postpartum women experience psychological distress including stress, depressive, or anxiety symptoms during the postpartum period. The purpose of this study was to explore the extent to which social determinants of health and allostatic load score, a 10-item index of biologic measures of chronic stress, predict psychological distress in low-income pregnant women over the first postpartum year. We conducted a secondary data analysis of the Child Community Health Research Network data set. The psychological distress outcome variables were perceived stress (n = 842), depression ( n = 845), and anxiety ( n = 846) symptoms, all measured categorically over the first year postpartum (T1:1 month, T2: 24-29 weeks, and T3: 50-65 weeks). Our predictors were social determinants of health (e.g., demographics, maternal hardship, percent poverty level, interpersonal violence, and food security) and allostatic load score. Generalized linear mixed models were used to determine which predictors were significantly associated with psychological distress symptoms across the first postpartum year. Interpersonal violence was a statistically significant risk factor for stress, depression, and anxiety symptoms over the first year postpartum. Other significant risk factors included low-income level, nativity, and perceived food security. Receiving food stamps was a significant protective factor for stress symptoms. The significance of risk factors for psychological distress, both modifiable and nonmodifiable, can be used as potential targets for further research, screening, and intervention. Future work should explore why and in what conditions these risk factors vary over time.

How Low-Income Mothers Select and Adapt Recipes and Implications for Promoting Healthy Recipes Online.

We describe a 5-year (2011⁻2015) qualitative evaluation to refine the content/delivery of the Food Hero social marketing campaign recipes to low-income mothers. Objectives were to: (1) identify characteristics looked for in recipes; (2) determine recipe sources; (3) understand motivation for seeking new recipes and recipe adaptations; and (4) identify recipe website characteristics users valued. Nine focus groups (n = 55) were conducted in Portland, Oregon. Participants (35⁻52 years) were primary caregivers for ≥ one child, the primary household food shoppers/preparers, enrolled in the Supplemental Nutrition Assistance Program (SNAP) and able to speak/read English. Participants reported having "go-to" family recipes and regularly searching online for new recipes, especially those using ingredients available/preferred by family members. Recipe websites with highest appeal were polished and engaging to mothers/children, offered user-ratings/comments and were reachable from search engines. Results identified key recommendations: (1) understand the target audience; (2) aim to add healthy/customizable recipes to family "go-to' recipe rotations and understand the impact of generational influences (e.g. how mothers/grandmothers cooked) on family meals; and (3) create websites that meet target audience criteria. Seeking the target audience's input about the content/delivery of recipes is an important formative step for obesity-prevention projects that include healthy recipes.

Low-income mothers' entry into postsecondary education during middle childhood: Effects on adolescents.

This study tests whether young adolescents' achievement and behavior are associated with their mother's entry into post-secondary education (PSE) during their middle childhood years. It also examines five family processes that may link maternal PSE to development in middle childhood (income, home learning environment, mother's educational expectations for child, maternal presence, and family affective climate). The sample selects low-income families from the National Longitudinal Survey of Youth of 1979. Propensity score weighting adjusts for mothers' self-selection into PSE. We find that adolescents whose mothers entered PSE in their middle childhood scored higher than their peers on math, but similarly on reading, behavior problems, delinquency, and substance use. There were no associations between mothers' PSE entry and the proposed mediators.

The effects of depressive symptom management interventions on low-income mothers: A systematic review and meta-analysis.

AIM: To evaluate the effects of depressive symptom management interventions (DSMI) for low-income mothers. BACKGROUND: Depressive symptoms and depression are common complications following childbirth. Depressive symptoms experienced by low-income mothers negatively affect infant-toddler development. DESIGN: A systematic review and meta-analysis was conducted to provide a synthesized and critical appraisal of the included studies. DATA SOURCES: We conducted a systematic search of randomized controlled trials in the following electronic databases through November 2017: PubMed, EMBASE, CINAHL, PsycInfo, and Cochrane Library CENTRAL. REVIEW METHODS: Ten studies were found in the systematic review of DSMI in terms of content, mode of delivery, session, and provider. We then conducted a meta-analysis of nine randomized controlled trials with 798 participants, comparing low-income mothers with and without DSMI. RESULTS: A significant effect was noted for DSMI in improving depressive symptoms in low-income mothers with young children and for interventions lasting 8 weeks or less. CONCLUSION: The meta-analysis suggested that DSMI for low-income mothers can be effective; however, the effectiveness varies by intervention type, intervention duration, and whether the mothers had other children. IMPACT: The findings of this study will contribute to the development of effective DSMI by providing scientific evidence for the development of such programmes for low-income mothers, especially with respect to target population and intervention duration.

Treatment of Maternal Depression With In-Home Cognitive Behavioral Therapy Augmented by a Parenting Enhancement: A Case Report.

Depression is prevalent among mothers who participate in home visitation programs. This case study describes In-Home Cognitive Behavior Therapy (IH-CBT), an empirically based treatment for depressed mothers that is strongly integrated with ongoing home visitation. The use of a Parenting Enhancement for Maternal Depression (PEMD) module was added to address parenting difficulties in a depressed mother. This case describes issues and challenges encountered in delivering treatment in the home with low-income, depressed mothers. Issues involving engagement, adaptation to the setting, responding to the unique needs of low-income mothers, and partnership with concurrent home visiting to optimize outcomes are considered. Long-term follow-up (18 months after the end of treatment) permits examination of sustainability of gains. Implications for treating this high-risk population are discussed.

Informal Support among Low-income Mothers Post Welfare Reform: A Systematic Review.

The vulnerability and instability of low-income mothers situated in a context with a weak public safety net make informal social support one of few options many low-income mothers have to meet basic needs. This systematic review examines (a) social support as an empirical construct, (b) the restricted availability of one important aspect of social support-informal perceived support, hereafter informal support-among low-income mothers, (c) the role of informal support in maternal, economic, parenting, and child outcomes, (d) the aspects of informal support that influence its effects, and (e) directions for future research. Traditional systematic review methods resulted in an appraisal of 65 articles published between January 1996 and May 2017. Findings indicated that informal support is least available among mothers most in need. Informal support provides some protection from psychological distress, economic hardship, poor parenting practices, and poor child outcomes. To promote informal support and its benefits among low-income families, future research can advance knowledge by defining the quintessential characteristics of informal support, identifying instruments to capture these characteristics, and providing the circumstances in which support can be most beneficial to maternal and child well-being. Consistent measurement and increased understanding of informal support and its nuances can inform intervention design and delivery to strengthen vulnerable mothers' informal support perceptions thereby improving individual and family outcomes.

Maternal Characteristics Associated With Social Support in At-Risk Mothers of Premature Infants.

OBJECTIVE: To identify maternal characteristics associated with social support among new mothers of premature infants who are at social-environmental risk. DESIGN: Cross-sectional analysis of intake interview data from a larger randomized controlled trial of a mother-premature infant developmentally based intervention. SETTING: Two urban community-based hospitals. PARTICIPANTS: One hundred ninety-four women (50% Black, 50% Hispanic) who recently gave birth to otherwise healthy, premature (29-34 weeks gestational age) infants. Participants had at least 2 of 10 social-environmental risks (e.g., poverty). METHODS: In-hospital interviews were conducted to obtain data on sociodemographic characteristics, prior mental health problems, and social support through the use of the Personal Resources Questionnaire 2000. Bivariate and multivariable linear regression analyses were performed to identify factors associated with social support. RESULTS: Mean Personal Resources Questionnaire 2000 scores were significantly lower for Hispanic than Black participants (92.0 vs. 96.0, respectively), those interviewed in Spanish versus English (89.8 vs. 96.1), those with low versus age-appropriate education levels (89.7 vs. 95.3), multiparous versus primiparous women (92.7 vs. 96.0), and those reporting versus not reporting histories of mental health problems (84.7 vs. 94.8). After multivariable adjustment, only younger age, Spanish language preference, multiparity, and a history of mental health problems were associated with significantly lower levels of social support (R2 = 0.18). CONCLUSION: More programs should be made available to provide social support to at-risk mothers, especially younger mothers, and those with limited English ability, other children at home, or histories of mental health problems. Nurses should target these mothers for additional support during their premature infants' NICU stay.

Maternal Strategies to Access Food Differ by Food Security Status.

BACKGROUND: Household food insecurity is associated with health and behavior risk. Much less is known about how food insecurity is related to strategies that adults use in accessing food: how and where they shop, use of alternative food sources, and their ability to manage resources. OBJECTIVE: To examine how maternal behaviors, including shopping, accessing alternative sources of food, and managing resources, are related to household food security status (HHFSS). DESIGN: Cross-sectional study collecting survey data on HHFSS, shopping behaviors, use of alternative food sources, and managing resources obtained from low-income mothers of preschool-aged children. PARTICIPANTS: One hundred sixty-four low-income mothers of young children (55% Hispanic) from two communities in Rhode Island. MEASURES: HHFSS was measured using 10 items from the 18-item Core Food Security Module to assess adult food security. Mothers were surveyed about where, when, and how often they shopped; the strategies they use when shopping; their use of alternative sources of food, including federal, state, and local assistance; and their ability to manage their resources. STATISTICAL ANALYSIS: Analysis of variance and χ2 analyses assessed the associations between demographic variables, shopping, accessing alternative food sources, and managing resources, and HHFSS. Multivariate logistic regression assessed the associations between HHFSS and maternal demographic variables, food shopping, strategies, alternative sources of food, and ability to manage resources. RESULTS: Maternal age and language spoken at home were significantly associated with HHFSS; food insecurity was 10% more likely among older mothers (adjusted odds ratio [aOR] 1.10, 95% CI 1.03 to 1.17) and 2.5 times more likely among Spanish-speaking households (compared with non-Spanish speaking [aOR 3.57, 95% CI 1.25 to 10.18]). Food insecurity was more likely among mothers reporting more informal strategies (aOR 1.98, 95% CI 1.28 to 3.01; P<0.05) and perceiving greater inability to manage resources (aOR 1.60, 95% CI 1.30 to 1.98; P<0.05). CONCLUSIONS: The results suggest that low-income mothers use a variety of strategies to feed their families and that the strategies they use vary by HHFSS. Community nutrition programs and providers will need to consider these strategies when counseling families at risk for food insecurity and provide guidance to minimize the influence on healthy food choices.

Low-Income First-Time Mothers: Effects of APN Follow-up Using Mobile Technology on Maternal and Infant Outcomes.

Background. Low-income mothers have greater challenges in accessing health care services due changes in the health care system and budget cuts. The purpose of this randomized clinical trial was to test a nurse practitioner (NP) intervention using cell phone and texting on maternal/infant outcomes. Methods. The sample included 129 mother-infant pairs. Intervention group mothers received NP 2-way cell phone follow-up intervention post-hospital discharge for 6 months. Results. Intervention mothers' perceived social support was significantly higher. Intervention infants received their first newborn follow-up visit significantly earlier (6 vs 9 days); significantly more infants were immunized at recommended times (2, 4, and 6 months of age); and there were fewer infant morbidities compared to controls. The intervention saved between $51 030 and $104 277 in health care costs averted. Conclusion. This easy-to-use, safe intervention is an effective way to reach a wide range of populations and demonstrated improved maternal/infant outcomes and decreased cost.

The Association of Low Social Support with Breast Milk Expression in Low-Income Mother-Preterm Infant Dyads.

BACKGROUND: Premature infants benefit from receiving expressed breast milk (BM), but expressing breast milk is difficult for new mothers. Little is known about mothers' social support and BM expression during the premature infant's hospital stay. OBJECTIVE: We examined whether low maternal social support was associated with breast milk expression initiation and low breast milk expression among low-income mothers of premature infants. METHODS: Maternal intake interview data and daily infant data on proportion of nutrition from BM during hospitalization were analyzed from a larger randomized trial testing a developmental intervention on 181 mother-premature infant dyads with at least 2 of 10 social-environmental risks. Multivariable modified Poisson regression was used to examine the relationship between social support (Personal Resources Questionnaire 2000; dichotomized as low for lowest quartile), initiation (any breast milk expressed vs none), and low breast milk expression (if BM was < 30% of infant total milk/formula intake during hospitalization). RESULTS: Breast milk expression was initiated by 70.2% of mothers, and 32.3% of those mothers had low breast milk expression. In adjusted multivariable analyses, social support did not relate to the initiation of breast milk expression but was significantly associated with low breast milk expression among mothers who initiated (adjusted relative risk = 1.57; 95% confidence interval, 1.00-2.47). CONCLUSION: Low social support was not associated with initiation but was associated with low breast milk expression during hospitalization. Interventions to enhance social support for mothers of premature infants, especially those reporting low social support from family and friends, may increase in-hospital expression and long-term breastfeeding.

Women's reasons for attrition from a nurse home visiting program.

OBJECTIVE: To describe mothers' reasons for leaving a home visiting program early. DESIGN: Qualitative descriptive study using semistructured interviews of mothers who dropped out of the Nurse-Family Partnership (NFP) and two focus groups with nurses and nurse supervisors at an NFP site. SETTING: A New York State site of a NFP home visitation program for low-income new mothers designed to improve the physical and emotional care of children. PARTICIPANTS: Participants included 21 mothers, 8 nurses, and 3 nurse-supervisors. METHODS: Semistructured interviews and focus groups were used to collect data, which were analyzed using content analysis. RESULTS: The program was not perceived to fit a mother's needs when she was overwhelmed with other responsibilities, the nurse did not meet her expectations, the content was not of interest, or the mother did not desire visits after the infant was born. Nurses and mothers described the need for mothers to have organizational and communication skills, such as keeping track of appointments, calling to reschedule, articulating needs, and asking for assistance. Disruptive external influences included nurse turnover and unstable living situations, including frequent moves and crowded housing. Each of these types of barriers had potential to interact with the others, creating complex combinations of challenges to retention. CONCLUSION: NFP retention might be improved by reframing program relevance to individual mothers and increasing maternal organizational and communication skill development.

Mother-infant interaction improves with a developmental intervention for mother-preterm infant dyads.

While premature infants have a high need for positive interactions, both infants and their mothers are challenged by the infant's biological immaturity. This randomized clinical trial of 198 premature infants born at 29-34 weeks gestation and their mothers examined the impact of the H-HOPE (Hospital to Home: Optimizing the Infant's Environment) intervention on mother-premature infant interaction patterns at 6-weeks corrected age (CA). Mothers had at least 2 social environmental risk factors such as minority status or less than high school education. Mother-infant dyads were randomly assigned to the H-HOPE intervention group or an attention control group. H-HOPE is an integrated intervention that included (1) twice-daily infant stimulation using the ATVV (auditory, tactile, visual, and vestibular-rocking stimulation) and (2) four maternal participatory guidance sessions plus two telephone calls by a nurse-community advocate team. Mother-infant interaction was assessed at 6-weeks CA using the Nursing Child Assessment Satellite Training-Feeding Scale (NCAST, 76 items) and the Dyadic Mutuality Code (DMC, 6-item contingency scale during a 5-min play session). NCAST and DMC scores for the Control and H-HOPE groups were compared using t-tests, chi-square tests and multivariable analysis. Compared with the Control group (n = 76), the H-HOPE group (n = 66) had higher overall NCAST scores and higher maternal Social-Emotional Growth Fostering Subscale scores. The H-HOPE group also had significantly higher scores for the overall infant subscale and the Infant Clarity of Cues Subscale (p < 0.05). H-HOPE dyads were also more likely to have high responsiveness during play as measured by the DMC (67.6% versus 58.1% of controls). After adjustment for significant maternal and infant characteristics, H-HOPE dyads had marginally higher scores during feeding on overall mother-infant interaction (ß = 2.03, p = 0.06) and significantly higher scores on the infant subscale (ß = 0.75, p = 0.05) when compared to controls. In the adjusted analysis, H-HOPE dyads had increased odds of high versus low mutual responsiveness during play (OR = 2.37, 95% CI = 0.97, 5.80). Intervening with both mother and infant is a promising approach to help premature infants achieve the social interaction patterns essential for optimal development.

The effects of Earned Income Tax Credit payment expansion on maternal smoking.

The Earned Income Tax Credit is the largest antipoverty program in the USA. In 1993, the Earned Income Tax Credit benefit levels were changed significantly based on the number of children in the family such that families with two or more children experienced an exogenous expansion in their incomes. Using data from the National Longitudinal Survey of Youth 1979 cohort, we use a triple-difference plus fixed effects framework to examine the effect of this change on the probability of smoking among low-educated mothers. We find that the probability of smoking for White low-educated mothers of two or more children significantly decreased relative to those with only one child, and this result is robust to various specification tests. This result provides new evidence on the protective effect of income on health through changes in a health-related behavior and therefore has important policy implications.