psychosocial stress and persistent racial disparities in adverse birth outcomes
DESCRIPTION
Tyan Parker Dominguez, PhD, MPH, MSW School of Social Work, University of Southern CaliforniaTRANSCRIPT
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Tyan Parker Dominguez, PhD, MPH, MSWTyan Parker Dominguez, PhD, MPH, MSW
School of Social WorkSchool of Social Work
University of Southern CaliforniaUniversity of Southern California
PSYCHOSOCIAL STRESS AND PSYCHOSOCIAL STRESS AND
PERSISTENT RACIAL PERSISTENT RACIAL
DISPARITIES IN ADVERSE DISPARITIES IN ADVERSE
BIRTH OUTCOMESBIRTH OUTCOMES
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1)1) Review the nature of persistent racial Review the nature of persistent racial disparities in adverse birth outcomesdisparities in adverse birth outcomes
2)2) Discuss the stress and pregnancy Discuss the stress and pregnancy paradigm, highlighting physiological paradigm, highlighting physiological mechanismsmechanisms
3)3) Present research findings from work on Present research findings from work on stress and birth outcomes stress and birth outcomes
OBJECTIVESOBJECTIVES
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Infant MortalityInfant Mortalitydeaths before age 1 per 1000 live birthsdeaths before age 1 per 1000 live births
OVERALL 6.8
NONHISPANIC WHITE 5.7
HISPANIC 5.4
ASIAN/PACIFIC ISLANDER
4.7
NONHISPANIC BLACK 13.5
Mathews, Menacker, & MacDorman, 2003 Mathews, Menacker, & MacDorman, 2003
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Preterm BirthPreterm Birth< 37 weeks gestation< 37 weeks gestation
Martin, Hamilton, Sutton, Ventura, Menacker, & Munson, 2003 Martin, Hamilton, Sutton, Ventura, Menacker, & Munson, 2003
OVERALL 12.1%
NONHISPANIC WHITE 11.0%
HISPANIC 11.6%
ASIAN/PACIFIC ISLANDER
10.4%
NONHISPANIC BLACK 17.7%
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OVERALL 7.8%
NONHISPANIC WHITE 6.9%
HISPANIC 6.5%
ASIAN/PACIFIC ISLANDER
7.8%
NONHISPANIC BLACK 13.4%
Martin, Hamilton, Sutton, Ventura, Menacker, & Munson, 2003 Martin, Hamilton, Sutton, Ventura, Menacker, & Munson, 2003
Low BirthweightLow Birthweight< 2500 grams< 2500 grams
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Disparity not explained by establishedDisparity not explained by established
SociodemographicSociodemographic
BehavioralBehavioral
MedicalMedical
risk factorsrisk factors
Berkowitz & Papiernik, 1993; Collins & David, 1990; David & Collins, 1991; Frisbie, Biegler, de Turk, Forbes, & Pullum, 1997; Berkowitz & Papiernik, 1993; Collins & David, 1990; David & Collins, 1991; Frisbie, Biegler, de Turk, Forbes, & Pullum, 1997; Kleinman & Kessel, 1987; Shiono, Klebanoff, Graubard, Berendes, & Rhoads, 1986; Wise, 1993Kleinman & Kessel, 1987; Shiono, Klebanoff, Graubard, Berendes, & Rhoads, 1986; Wise, 1993
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P s y c h o s o c i a l S t r e s sP s y c h o s o c i a l S t r e s s
Environmental demands that tax or Environmental demands that tax or
exceed the adaptive capacity of an exceed the adaptive capacity of an
organism, resulting in physiological organism, resulting in physiological
and psychological changes that may and psychological changes that may
place the organism at risk for place the organism at risk for
diseasedisease
Cohen, Kessler, & Gordon, 1995Cohen, Kessler, & Gordon, 1995
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African-American pregnant women report African-American pregnant women report more stress exposure and greater emotional more stress exposure and greater emotional distress from that exposure than other distress from that exposure than other groupsgroups
Feldman, Dunkel-Schetter, Woo & Hobel, 1997; Zambrana et al., 1999 Feldman, Dunkel-Schetter, Woo & Hobel, 1997; Zambrana et al., 1999
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A Biopsychosocial ModelA Biopsychosocial Model
Neuroendocrine Neuroendocrine systemsystem
Immune Immune systemsystem
Cardiovascular Cardiovascular systemsystem
STRESSSTRESSBirth Birth
outcomesoutcomes
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The health of minority groups is intimately The health of minority groups is intimately
connected to the connected to the HIGH STRESS HIGH STRESS STATESSTATES
created by a social system that condones, created by a social system that condones,
reinforces, and perpetuates racial reinforces, and perpetuates racial
discrimination.discrimination. Myers, 1982
Negative Self-Society DialecticNegative Self-Society Dialectic
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RACISM LINKED TORACISM LINKED TODecreased life satisfactionDecreased life satisfaction
PRETERM PRETERM DELIVERYDELIVERYLOW LOW
BIRTHWEIGHTBIRTHWEIGHT
INFANT INFANT MORTALITYMORTALITY
Cardiovascular diseaseCardiovascular diseaseStrokeStroke
High blood pressureHigh blood pressure
Psychological distressPsychological distress DepressionDepression
Lower self-esteemLower self-esteem
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ALLOSTATIC LOADALLOSTATIC LOADPhysiologic toll of repeated and/or chronic Physiologic toll of repeated and/or chronic
stress system activationstress system activation
StressStress
BaselineBaseline
RecoveryRecovery
AllostasisAllostasis Allostatic LoadAllostatic Load
BaselineBaseline
McEwen & Stellar, 1993; Sterling & Eyer, 1988McEwen & Stellar, 1993; Sterling & Eyer, 1988
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RACISM AND ADVERSE RACISM AND ADVERSE
PREGNANCY OUTCOMESPREGNANCY OUTCOMES
A Program of ResearchA Program of Research
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• Prospective, repeated measures surveyProspective, repeated measures survey
• Psychosocial, medical, physiological variablesPsychosocial, medical, physiological variables
• 480 ethnically/SES diverse pregnant women480 ethnically/SES diverse pregnant women
• Recruited in clinics or referred by MDsRecruited in clinics or referred by MDs
• Fluent EnglishFluent English
• >> 18 yrs 18 yrs
• < < 18 wks gestation, non substance using18 wks gestation, non substance using
Multi-Site Behavior in Pregnancy StudyMulti-Site Behavior in Pregnancy Study
1997-20021997-2002
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STUDY 1
Does stress mediate racial differences in birth outcomes?
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2005
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N = 124N = 124
African-American (n=51) African-American (n=51)
Nonhispanic White (n=73)Nonhispanic White (n=73)
Born and raised in U.S.Born and raised in U.S.
Live-born infantLive-born infant
T1, T2, birth outcome dataT1, T2, birth outcome data
STUDY SAMPLESTUDY SAMPLE
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RACISM EXPOSURERACISM EXPOSURE
• personal/vicarious experiencespersonal/vicarious experiences• childhood/adulthood childhood/adulthood • across different life domainsacross different life domains
Have you ever felt that you (or someone close to Have you ever felt that you (or someone close to you) were (was) discriminated against or the target you) were (was) discriminated against or the target of prejudice because of race in interpersonal, of prejudice because of race in interpersonal, housing, employment, educational, other situations?housing, employment, educational, other situations?
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Sobel test of mediation = -1.64, p < .10 (one-tailed)
Mediation Models
DV = BW Step 1 Step 2 Step 3
GA .65*** .67*** .65**
Medrisk .05 .03 .04
Spont. Labor -.01 -.00 .01
Parents’ Educ .06 .03 .05
Race -.18* -.13+
Racism-Life -.13+
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Sobel test of mediation = -1.97, p < .05 (one-tailed)
Mediation Models
DV = BW Step 1 Step 2 Step 3
GA .65*** .67*** .64**
Medrisk .05 .03 .03
Spont. Labor -.01 -.00 .02
Parents’ Educ .06 .03 .05
Race -.18* -.13+
Racism-ChV -.16*
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K E Y F I N D I N G
Racism exposure, particularly vicarious childhood
experiences, predicts BW and attenuates race effects on BW,
controlling for confounders
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STUDY 2Are there physiological
factors that link racism
to birth outcomes?
Parker Dominguez, Hilmert, Dunkel Schetter, Glynn, Sandman, & Hobel, 2005
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C R H
A C T H
C O R T I S O L
Assayed from blood at
10-12 weeks, 18-20 weeks, 24-26 weeks,
30-32 weeks, and 34-36 weeks gestation
Neuroendocrine VariablesNeuroendocrine Variables
++--
mothermother
++++
placentaplacenta
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NE levels rise across pregnancy course in both ethnic groups
ETHNIC COMPARISON
Evidence of possible NE dysregulation in African Americans:
- high ACTH, low CRH and Cortisol
- smaller level of change in CRH and Cortisol
HOWEVERHOWEVER
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Racism, NE Function and BW
Vicarious Childhood Exposure
+CRH 34-36 weeks Birthweight
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Sobel_ChV = -1.91, p < .05; Sobel_NE = -1.71, p < .05
Mediation Models
DV = BW Step 1 Step 2 Step 3
GA .53*** .50*** .51**
Medrisk .17 .15 .10
Spont. Labor .00 .02 .02
Parents’ Educ .06 .10 .08
Race -.30** -.22* -.22+
Racism-ChV -.22* -.16+
CRH 32-36wks .20*
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K E Y F I N D I N G S1. Evidence of NE dysregulation in AfrAms
2. Racism associated with AfrAm NE pattern
3. Late term CRH predicts BW and mediates ChV racism effects on BW
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STUDY 3Are there differences across
multiple racial/ethnic groups in
exposure to and impact of racism?
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
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70 70 LatinasLatinas
177 177 Nonhispanic WhitesNonhispanic Whites
25 25 Asian/Pacific Asian/Pacific
IslandersIslanders
5151 African-AmericansAfrican-Americans
with racism datawith racism data
MS-BIPS SAMPLE consisted ofMS-BIPS SAMPLE consisted of
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Variable AfrAm API Latina White p-value
DSCR_C 3.2(3.2) 3.1(2.4) 1.4(1.9) 1.0(1.7) 0.000
DSCR_D 72.5% 88.0% 54.3% 40.7% 0.000
RACISM EXPERIENCESRACISM EXPERIENCES
LIFETIMELIFETIME
Unadj: APIs & AfrAms / Latinas & Whites
Adj: Latinas / Whites
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
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DISTRESSDISTRESS
AfrAms and Latinas were significantly less distressed than APIs and Whites
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RESPONSERESPONSE
•AfrAms significantly more likely to keep racism experiences to themselves
•AfrAms significantly more likely to accept unfair treatment as a fact of life
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Associations with RacismAssociations with Racism
VariableVariable rr bb
PSSPSS 0.270.27**** 0.230.23****
STAISTAI 0.300.30**** 0.300.30****
Preg AnxPreg Anx 0.240.24**** 0.220.22****
CES-DCES-D 0.180.18**** 0.150.15**
ResourcesResources -0.14-0.14** -0.14-0.14**
* p<0.05, ** p<0.01* p<0.05, ** p<0.01
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
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Associations with RacismAssociations with Racism
VariableVariable rr bb
BWBW -0.13-0.13** -0.08-0.08
GAGA -0.12-0.12** -0.10-0.10
*p<0.05*p<0.05
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
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Interaction EffectsInteraction Effects
= .22, p < .05
APIs: = .07, p > .10
AfrAms: = -.36, p < .05
Racism and BW
African Americans X APIs
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K E Y F I N D I N G S• Ethnic differences in racism exposure, Ethnic differences in racism exposure,
distress, and copingdistress, and coping
• Racism impacts psychosocial fx of all Racism impacts psychosocial fx of all groupsgroups
• Evidence race may moderate racism Evidence race may moderate racism effects on birth outcomeseffects on birth outcomes
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Improved racism measures Improved racism measures
Multi-level studiesMulti-level studies
Lifespan Approach Lifespan Approach
CBPRCBPR
Interdisciplinary teamsInterdisciplinary teams
Looking ahead…..
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Christine Dunkel SchetterChristine Dunkel Schetter
Department of Psychology, UCLADepartment of Psychology, UCLA
Laura GlynnLaura Glynn
Department of Psychiatry, UC-IrvineDepartment of Psychiatry, UC-Irvine
Calvin J. HobelCalvin J. Hobel
Department of Maternal/Fetal Med, Cedars-SinaiDepartment of Maternal/Fetal Med, Cedars-Sinai
Curt SandmanCurt Sandman
Department of Psychiatry, UC-IrvineDepartment of Psychiatry, UC-Irvine
AcknowledgementsAcknowledgements