Strengthening Recruitment and Retention: Mitigation Strategies in Two Longitudinal Studies of Pregnant Women in Pakistan.

PURPOSE: Global health researchers have a responsibility to conduct ethical research in a manner that is culturally respectful and safe. The purpose of this work is to describe our experiences with recruitment and retention in Pakistan, a low-middle-income country. DESCRIPTION: We draw on two studies with a combined sample of 2161 low-risk pregnant women who participated in a pilot (n = 300) and a larger (n = 1861) prospective study of psychological distress and preterm birth at one of four centers (Garden, Hyderabad, Kharadar, Karimabad) of the Aga Khan University Hospital in Karachi, Pakistan. ASSESSMENT: Challenges we encountered include economic hardship and access to healthcare; women's position in the family; safety concerns and time commitment; misconceptions and mistrust in the research process; and concerns related to blood draws. To mitigate these challenges, we developed culturally acceptable study incentives, involved family members in the decision-making process about study participation, partnered with participants' obstetrician-gynecologists, accommodated off site study visits, combined research visits with regular prenatal care visits, and modified research participation related to blood draws for some women. CONCLUSION: Implementation of these mitigation strategies improved recruitment and retention success, and we are confident that the solutions presented will support future scientists in addressing sociocultural challenges while embarking on collaborative research projects in Pakistan and other low-middle-income countries.

Physiological and affective responses to green space virtual reality among pregnant women.

BACKGROUND: Benefits of green spaces on stress reduction have been shown in previous studies. Most existing studies to date have focused on the general population. However, there is a lack of understanding of physiological mechanisms underlying the beneficial effects of green space among special populations, such as pregnant women. OBJECTIVES: To examine physiological and affective responses to green space on stress recovery among pregnant women, using simulated green space exposure through virtual reality (VR). METHODS: We recruited 63 pregnant women between 8 and 14 weeks' gestational age for a laboratory experiment. Participants were randomly assigned to view one of three, 5-min, VR videos of an urban scene with different green space levels (i.e., non-green, moderate, and high) after a laboratory stressor, the Trier Social Stress Test. Physiological stress responses were measured via changes in blood pressure, heart rate, skin conductance level, salivary alpha-amylase, and salivary cortisol. Affective response was measured using the Positive and Negative Affect Scale. RESULTS: We found that visual exposure to a green space environment in VR was associated with both physiological and affective stress reduction among pregnant women, including lower systolic blood pressure [-4.6 mmHg, 95% confidence interval (CI): -8.8, -0.4], reduced salivary alpha-amylase concentration (-1.2 ng/ml, 95% CI: -2.2, -0.2), improved overall positive affect (score: 6.6, 95% CI: 0.3, 13.0) and decreased negative affect of anxiety (score: -2.6, 95% CI: -5.19, -0.04) compared to non-green space environment. Exposure to high green space environment in park-like setting had the strongest impacts on stress recovery. CONCLUSION: This study demonstrated that virtual green space exposure could effectively ease stress and improve mental health and well-being during pregnancy. Even a short immersion in VR-based green space environment may bring health benefits, which has significant implications for pregnant women when access to an actual nature may not be possible.

Does perceived support moderate the link between acculturative stress and problematic eating behaviors? The role of family, significant other, and friend support.

OBJECTIVE: Acculturative stress, often experienced by members of minority groups, is related to problematic eating behaviors. What remains poorly understood is the function of perceived social support in this link. This study evaluated the moderating role of perceived support from family, the significant other, and friends in the association between acculturative stress and problematic eating behaviors, including emotional eating, uncontrolled eating, and cognitive restraint eating. METHOD: An online cross-sectional study was conducted with 497 Asian and Latinx college students using standardized questionnaires. Three hierarchical multivariable models were analyzed, with each eating behavior included as the outcome variable. Demographic variables (Step 1), general perceived stress (Step 2), and predictor variables (i.e., acculturative stress, perceived support; Step 3) were added using Method Enter. Interaction terms were entered using Method Stepwise (Step 4) to test for moderation effects. RESULTS: As perceived family support increased, the magnitude of the link between acculturative stress and higher uncontrolled eating increased (p = .002). When perceived significant other support was higher, the magnitude of the relationship between acculturative stress and higher emotional eating increased (p = .02). Higher perceived friend support was directly related to reduced uncontrolled eating (p = .002). DISCUSSION: This study highlights the heterogeneous effects of various sources of perceived support on the link between acculturative stress and problematic eating behaviors. Findings imply that problematic eating prevention and intervention programs might benefit from considering not only the acculturative stress experienced by racial/ethnic minority young adults but also the sources of support perceived. PUBLIC SIGNIFICANCE: Perceived support from family and the significant other increased the magnitude of the link between higher acculturative stress and increased problematic eating behaviors, whereas support from friends showed a direct relationship with reduced uncontrolled eating. The results highlight the nuanced functions of various sources of perceived social support and contribute to a deeper understanding of potential moderators in the relationship between acculturative stress and problematic eating behaviors among racial/ethnic minorities.

Domestic violence assault during the first year of the COVID-19 pandemic: a longitudinal community study.

BACKGROUND: The consequences of the COVID-19 pandemic have been far-reaching, disproportionately impacting vulnerable populations. Of particular concern is the impact on individuals experiencing domestic violence (DV), an urgent public health issue. There have been numerous reports of pandemic-related surges in DV, and it has been speculated that prolonged periods of state-mandated isolation may be the source of these surges. The current study utilized publicly available records to examine fluctuations in DV coinciding with COVID-19 lockdown restrictions in a diverse metropolitan county. METHODS: Data were extracted from local police blotters and mapping engines in Orange County, California (United States), documenting police-reported DV assault. All incidents were coded for time to examine the time course of DV among other types of assault, allowing for a longitudinal view of incidents over a 66-week window. Changepoint analyses were used to determine whether and when DV assaults changed when mapped with coinciding tightening or loosening of restrictions county-wide. Piecewise regression analyses evaluated whether any detected fluctuations were statistically meaningful. RESULTS: In Santa Ana, rates saw a small but significant spike in the week following the first major lockdown in March 2020 (b = .04, SE = .02, t = 2.37, p = .01), remaining stable at this higher level thereafter (b = -.003, SE = .003, t = -1.29, p = .20). In Anaheim, no meaningful change in DV assault rates was observed at any time interval. CONCLUSION: Results suggest that surges in DV vary between communities and that systemic issues may set the stage for the surge of an already endemic problem.

Is HbA1c associated with birth weight? A multivariable analysis of Pakistani pregnant women.

AIM: Globally, one in seven infants is born with low birth weight and 3%-7% of infants are born with high birth weight, with the greatest burden noted in low- and middle-income countries. This study investigated the association between maternal prenatal glucose regulation and birth weight and the moderating effect of fetal sex among Pakistani women. METHODS: Secondary data from a prospective longitudinal study of healthy pregnant women from Pakistan (N = 189) was used. Participants provided a blood sample (12-19 weeks' gestational age) for the assessment of HbA1c (%). Birth weight (g) was collected following delivery. RESULTS: Higher maternal HbA1c was associated with higher birth weight (b = 181.81, t[189] = 2.15, p = 0.03), which was moderated by fetal sex (b = -326.27, t[189] = -2.47, p = 0.02), after adjusting for gestational age at birth, ethnicity, and pregnancy weight. Among women carrying a male fetus, every 1% increase in HbA1c predicted a 182 g increase in birth weight (b = 181.81, t[189] = 2.15, p = 0.03). CONCLUSIONS: Results extend research from high-income countries and indicate that fetal sex may have implications for glucose regulation in early to mid-pregnancy. Future research should examine sociocultural factors, which could elucidate potential mediating factors in the relation between HbA1c and birth weight in healthy pregnancies.

Acculturative stress and eating disinhibition among Asian young adults: The role of depressive symptoms and gender.

Acculturative stress is associated with health behaviors that have downstream consequences for health outcomes. Eating disinhibition, a behavior characterized by eating emotionally and uncontrollably in the presence of disinhibiting stimuli, has been consistently associated with acculturative stress, but the underlying mechanism is not well-understood. The current study sought to test the role of depressive symptoms and gender on these associations. Asian undergraduate students (N = 477; 78% female) participated in an online cross-sectional study. Higher acculturative stress was associated with higher eating disinhibition (b = 3.45, 95% CI = [0.75, 6.15]), and depressive symptoms showed a partial indirect effect on this association (indirect effect = 0.57, 95% CIboot = [0.13, 1.34]). Among male young adults (b = 0.98, 95% CIboot = [0.24, 2.39]), the indirect correlation was stronger than among female young adults (b = 0.44, 95% CIboot = [0.05, 1.20]; non-significant trend), implying individual differences underlying the indirect effect of depressive symptoms in the acculturative stress and eating disinhibition correlation. The Intercultural Relations dimension of acculturative stress appeared to drive the observed associations. This study is among the first highlighting the role of acculturative stress, depressive symptoms, and gender in eating disinhibition and provides evidence that can inform health professionals to target at-risk Asian individuals with eating problems.

Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review.

INTRODUCTION: Total adverse childhood experiences (ACEs) are gaining prominence as a risk factor for preterm birth (PTB). The emerging literature examining this relationship reports inconsistent findings. The purpose of this systematic review was to summarize the available evidence exploring whether total ACEs predict PTB. METHODS: A total of 386 studies were returned from searches on PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Nine studies were selected for final analysis and synthesis based on reporting of total ACEs and preterm birth gestational weeks or standard definition of birth before 37 weeks' gestational age. A systematic review rather than meta-analysis was selected to present the findings given the clinical and methodological (e.g., sample studied, measurement tools) heterogeneity of the retrieved studies and pregnancy outcomes measured. RESULTS: The nine studies report on birth outcomes for 6,087 women from a range of sociodemographic and ethnic backgrounds. Despite a wide range of study designs, measurement tools, and timings of ACEs exposure across studies, seven of the nine included studies showed significant relationships between ACEs and PTB. CONCLUSION: Systematic review of the literature suggests that total ACEs are associated with PTB and provides an overview on the known associations. However, to date only nine studies have assessed this link, and more studies are needed, to explore the associations between ACEs and PTB using appropriate and valid instruments and doing so among more diverse populations. Future research should also explore possible biological mechanisms (allostatic load), and moderating and mediating variables.

Measurement of a Latino cultural value: The Simpatía scale.

OBJECTIVE: Simpatía, a term that captures the tendency to prefer and create social interactions characterized by warmth and emotional positivity while also avoiding conflict and/or overt negativity, is a cultural factor relevant to Latinos. The goal of this article was to develop a scale that measures this cultural value. METHOD: A self-report scale measure of simpatía was developed and administered to a combined sample of Latinos (N = 296) drawn from 3 larger studies. The scale's factor structure was explored, and its internal consistency and validity were tested. RESULTS: Exploratory factor analysis supported an 18-item scale and indicated 2 factors: simpatía-related positivity/warmth and simpatía-related negativity/conflict avoidance. Cronbach's alphas for the overall scale and subscales showed internal consistency. Validity analyses revealed that across subscales, simpatía was positively associated with positive emotion expressivity and dispositional positive emotion. The simpatía-related positivity/warmth subscale was also positively associated with an orientation toward Latino culture. CONCLUSIONS: The Simpatía Scale, which captures dual aspects of simpatía that emphasize the positive and avoid the negative, provides a new tool for advancing the study of Latino culture. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A systematic review of concepts related to women's empowerment in the perinatal period and their associations with perinatal depressive symptoms and premature birth.

BACKGROUND: The perinatal period, which we here define as pregnancy and the first year postpartum, is a time in women's lives that involves significant physiological and psychosocial change and adjustment, including changes in their social status and decision-making power. Supporting women's empowerment at this particular time in their lives may be an attractive opportunity to create benefits for maternal and infant health outcomes such as reductions in perinatal depressive symptoms and premature birth rates. Thus, we here systematically review and critically discuss the literature that investigates the effects of empowerment, empowerment-related concepts and empowerment interventions on reductions in perinatal depressive symptoms, preterm birth (PTB), and low birthweight (LBW). METHODS: For this systematic review, we conducted a literature search in PsychInfo, PubMed, and CINAHL without setting limits for date of publication, language, study design, or maternal age. The search resulted in 27 articles reporting on 25 independent studies including a total of 17,795 women. RESULTS: The majority of studies found that, for the most part, measures of empowerment and interventions supporting empowerment are associated with reduced perinatal depressive symptoms and PTB/LBW rates. However, findings are equivocal and a small portion of studies found no significant association between empowerment-related concepts and perinatal depressive symptoms and PTB or LBW. CONCLUSION: This small body of work suggests, for the most part, that empowerment-related concepts may be protective for perinatal depressive symptoms and PTB/LBW. We recommend that future theory-driven and integrative work should include an assessment of different facets of empowerment, obtain direct measures of empowerment, and address the relevance of important confounders, including for example, ethnicity and socioeconomic status.

Discrimination and the HPA axis: current evidence and future directions.

Numerous studies suggest that discrimination is associated with poor physical and mental health outcomes. Whereas the cardiovascular system has been extensively studied as a potential pathway linking discrimination with disease, the role of the hypothalamic-pituitary-adrenal (HPA) axis remains understudied. We conducted a systematic review of research on discrimination and related constructs as predictors and correlates of HPA axis activity. Twenty seven studies (10 experimental, 17 observational) met inclusion criteria. Studies suggest that discrimination is associated with alterations in HPA axis activity and that the direction of this association depends on the timing and chronicity of the discrimination experience. There is also evidence of important modulating variables (race, socioeconomic status) and contextual confounders (emotional, situational) that warrant further study. Accounting for the HPA axis in addition to the cardiovascular system will contribute to a more comprehensive understanding of the biobehavioral pathways contributing to physical and mental health inequities related to discrimination.

Stress and emotional valence effects on children's versus adolescents' true and false memory.

Despite considerable interest in understanding how stress influences memory accuracy and errors, particularly in children, methodological limitations have made it difficult to examine the effects of stress independent of the effects of the emotional valence of to-be-remembered information in developmental populations. In this study, we manipulated stress levels in 7-8- and 12-14-year-olds and then exposed them to negative, neutral, and positive word lists. Shortly afterward, we tested their recognition memory for the words and false memory for non-presented but related words. Adolescents in the high-stress condition were more accurate than those in the low-stress condition, while children's accuracy did not differ across stress conditions. Also, among adolescents, accuracy and errors were higher for the negative than positive words, while in children, word valence was unrelated to accuracy. Finally, increases in children's and adolescents' cortisol responses, especially in the high-stress condition, were related to greater accuracy but not false memories and only for positive emotional words. Findings suggest that stress at encoding, as well as the emotional content of to-be-remembered information, may influence memory in different ways across development, highlighting the need for greater complexity in existing models of true and false memory formation.

Biological and psychosocial predictors of postpartum depression: systematic review and call for integration.

Postpartum depression (PPD) adversely affects the health and well being of many new mothers, their infants, and their families. A comprehensive understanding of biopsychosocial precursors to PPD is needed to solidify the current evidence base for best practices in translation. We conducted a systematic review of research published from 2000 through 2013 on biological and psychosocial factors associated with PPD and postpartum depressive symptoms. Two hundred fourteen publications based on 199 investigations of 151,651 women in the first postpartum year met inclusion criteria. The biological and psychosocial literatures are largely distinct, and few studies provide integrative analyses. The strongest PPD risk predictors among biological processes are hypothalamic-pituitary-adrenal dysregulation, inflammatory processes, and genetic vulnerabilities. Among psychosocial factors, the strongest predictors are severe life events, some forms of chronic strain, relationship quality, and support from partner and mother. Fully integrated biopsychosocial investigations with large samples are needed to advance our knowledge of PPD etiology.

Stress, interviewer support, and children's eyewitness identification accuracy.

Few studies have investigated how stress affects eyewitness identification capabilities across development, and no studies have investigated whether retrieval context in conjunction with stress affects accuracy. In this study, one hundred fifty-nine 7- to 8- and 12- to 14-year-olds completed a high- or low-stress laboratory protocol during which they interacted with a confederate. Two weeks later, they attempted to identify the confederate in a photographic lineup. The lineup administrator behaved in either a supportive or a nonsupportive manner. Participants who experienced the high-stress event and were questioned by a supportive interviewer were most accurate in rejecting target-absent lineups. Results have implications for debates about effects of stress on eyewitness recall, how best to elicit accurate identifications in children, and developmental changes in episodic mnemonic processes.

The symphonic structure of childhood stress reactivity: patterns of sympathetic, parasympathetic, and adrenocortical responses to psychological challenge.

Despite widespread recognition that the physiological systems underlying stress reactivity are well coordinated at a neurobiological level, surprisingly little empirical attention has been given to delineating precisely how the systems actually interact with one another when confronted with stress. We examined cross-system response proclivities in anticipation of and following standardized laboratory challenges in 664 4- to 14-year-olds from four independent studies. In each study, measures of stress reactivity within both the locus coeruleus-norepinephrine system (i.e., the sympathetic and parasympathetic branches of the autonomic nervous system) and the corticotrophin releasing hormone system (i.e., the hypothalamic-pituitary-adrenal axis) were collected. Latent profile analyses revealed six distinctive patterns that recurred across the samples: moderate reactivity (average cross-system activation; 52%-80% of children across samples), parasympathetic-specific reactivity (2%-36%), anticipatory arousal (4%-9%), multisystem reactivity (7%-14%), hypothalamic-pituitary-adrenal axis specific reactivity (6%-7%), and underarousal (0%-2%). Groups meaningfully differed in socioeconomic status, family adversity, and age. Results highlight the sample-level reliability of children's neuroendocrine responses to stress and suggest important cross-system regularities that are linked to development and prior experiences and may have implications for subsequent physical and mental morbidity.

Effects of stress on memory in children and adolescents: testing causal connections.

Although a sizeable body of research has examined children's memory for stressful prior experiences, relatively few studies have experimentally manipulated stress during a to-be-remembered event to draw causal inferences about the effects of stress, especially across wide age ranges. We exposed children and adolescents to a more or a less arousing version of the Trier Social Stress Test-Modified (TSST-M), a widely used laboratory stress task. Two weeks later, we tested their memory for what happened. Interviewers behaved in a supportive or non-supportive manner. In adolescents, those who completed the high-arousal TSST-M provided fewer correct responses to recognition questions and fewer incorrect responses to misleading questions for which any answer would have been incorrect, compared to those who completed the lower-arousal TSST-M. Thus, arousal seemed to have reduced the adolescents' willingness to answer questions rather than having influenced their memory per se. In children, across TSST-M conditions, greater physiological arousal during the TSST-M predicted enhanced recall. Finally, interviewer support reduced the amount of factual information provided in free recall but increased correct responses to misleading questions. Results highlight the complex ways in which event stress and interviewer demeanour shape recounting of prior experiences across development.

Are the costs of neuroticism inevitable? Evidence of attenuated effects in U.S. Latinas.

Neuroticism is the heritable and stable personality trait defined by the tendency to experience negative emotion, be easily stressed, and slow to soothe. Neuroticism poses a risk for poor social and health outcomes that has been identified as a major public health concern. To date, factors that attenuate neuroticism's costs have not been identified. The goal of this work was to test the hypothesis that the costs of neuroticism would be attenuated in sociocultural contexts that emphasize readily accessible social support, emotional positivity, and physical proximity in interdependent relationships. U.S. Latino culture fits these characteristics. Two studies, an online survey study (Study 1) and a laboratory study (Study 2), tested whether three key costs of high neuroticism-less support (Study 1), more distress (Study 2), and blunted cortisol reactivity (Study 2)-would be attenuated in U.S. Latinas relative to non-Latinas of European and East Asian cultural background. Consistent with previous research, neuroticism was associated with less perceived support, more distress, and blunted cortisol reactivity in non-Latina women of European and East Asian cultural background. For Latina women, however, these effects were attenuated. Latina women who were high in neuroticism continued to feel supported, were not as distressed, and their cortisol reactivity was less blunted. The role of sociocultural context for generating a better understanding of personality processes and the social malleability of neuroticism's costs are discussed.

Stress at encoding, context at retrieval, and children's narrative content.

Research concerning the relations between stress and children's memory has been primarily correlational and focused on memory volume and accuracy. In the current study, we experimentally manipulated 7- and 8-year-olds' and 12- to 14-year-olds' experienced stress during a to-be-remembered event to examine the effects of stress on the content of their memory. We further manipulated the degree of interviewer support at retrieval to determine whether it moderated the effects of stress at encoding on memory. Children's age, gender, stress at encoding, and interviewer support all influenced the type of information included in their narrative reports. Most notably, across ages, children who experienced a more stressful event but were questioned in a supportive manner provided the largest ratio of terms representing internal states such as those about cognitions and emotions. Results suggest that how children process past events may be influenced by both the nature of the event itself and the context within which it is recalled.

Maternal Diet Quality and Prenatal Depressive Symptoms: The Moderating Role of Economic Well-Being.

Prenatal depression is prevalent and adversely impacts maternal and infant health. This study addresses a critical literature gap and investigates the association between maternal diet quality and prenatal depressive symptoms, as well as the moderating effect of economic well-being on this link. A cross-sectional design was used, including 43 healthy pregnant women in the second trimester aggregated from two research projects. Prenatal depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale. Dietary quality was evaluated using two non-consecutive 24 h dietary recalls, from which the Adapted Dietary Inflammatory Index (ADII) and the Healthy Eating Index (HEI)-2015 were derived. Economic well-being was indicated by the income-to-poverty ratio. A higher HEI-2015 (adherence to dietary guidelines; ß = -0.53, p = 0.01) and negative ADII (anti-inflammatory diet; ß = 0.40, p = 0.06) were associated with fewer prenatal depressive symp-toms. Among pregnant women with worse economic well-being, a pro-inflammatory diet was as-sociated with more prenatal depressive symptoms (b = 1.69, p = 0.004), but among those with better economic well-being, the association was not significant (b = 0.51, p = 0.09). Dietary interventions aimed at reducing dietary inflammation might hold some promise for improving mental health among pregnant women who are economically vulnerable.

Attachment insecurity, heart rate variability, and perceived social support in a diverse sample of young adults.

Psychological and physical factors are robustly associated with perceived social support. Drawing from the literature on attachment style in adults and psychophysiology, we examined the possibility that the interaction of attachment insecurity and resting heart rate variability (HRV) was associated with perceived social support in a diverse sample of young adults living in the U.S (N = 145, Mage = 20.45) that was majority Latino (n = 77). Analyses revealed three key findings. First, in the overall sample, attachment avoidance and attachment anxiety were negatively associated with perceived social support, but in the Latino sample, only attachment avoidance was negatively associated with perceived social support. Second, HRV was not associated with perceived social support in the overall sample nor in the Latino sample. Third, attachment insecurity and HRV interacted to predict perceived social support only in the Latino sample such that, for those with lower levels of HRV, attachment anxiety was positively associated with perceived social support. This study underscores the importance of examining both psychological and physiological processes with careful consideration of ethnicity/culture in order to better understand perceived social support.

Individual and collective contribution of antenatal psychosocial distress conditions and preterm birth in Pakistani women.

BACKGROUND: We determined whether dimensions of psychosocial distress during pregnancy individually and collectively predicted preterm birth (PTB) in Pakistani women as it may be misleading to extrapolate results from literature predominantly conducted in high-income countries. METHODS: This cohort study included 1603 women recruited from four Aga Khan Hospital for Women and Children in Sindh, Pakistan. The primary binary outcome of PTB (i.e., livebirth before 37 completed weeks' gestation) was regressed on self-reported symptoms of anxiety (Pregnancy-Related Anxiety (PRA) Scale and Spielberger State-Trait Anxiety Inventory Form Y-1), depression (Edinburgh Perinatal Depression Scale (EPDS)), and covariates such as chronic stress (Perceived Stress Scale) assessed with standardized question and scales with established language equivalency (Sindhi and Urdu). RESULTS: All 1603 births occurred between 24 and 43 completed weeks' gestation. PRA was a stronger predictor of PTB than other types of antenatal psychosocial distress conditions. Chronic stress had no effect on the strength of association between PRA and PTB and a slight but non-significant effect on depression. A planned pregnancy significantly lowered risk of PTB among women who experienced PRA. Aggregate antenatal psychosocial distress did not improve model prediction over PRA. CONCLUSIONS: Like studies in high-income countries, PRA became a strong predictor of PTB when considering interactive effects of whether the current pregnancy was planned. Women's resilience and abilities to make sexual and reproductive health decisions are important to integrate in future research. Findings should be generalized with caution as socio-cultural context is a likely effect modifier. We did not consider protective/strength-oriented factors, such as resilience among women.