Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003

Improving the Mental Health of Women Recognition and Treatment of Depression

LISA R. FORTUNA:  So I'm Dr. Fortuna, and I am working with Dr. Witt, who you've just heard, on this presentation, which is looking at Pap screening among Hispanic mothers.  And what we looked at here is basically looking at influence of years living in the United States and language, so some markers of acculturation and depressive symptoms and how that impacts on Pap screening for this population.  So I will also sort of do these things in my talk, including looking about the background, methods, results, summary conclusions, strengths and limitations, and then again, of course, some of the policy implications of what we have found. 

In terms of the background, as we know, and there's a lot of literature on this about that there's disproportionate percentage of Hispanic women are at risk of being unscreened for cervical cancer and, therefore, having some difficulty with having cervical cancer that's more progressed.  Both cultural language acculturation issues and socioeconomic barriers, including insurance status or lack of insurance, have been implicated as barriers of preventative care for Hispanic woman, and that has been seen in the literature.  But also mental health problems have been associated with poor medical care and follow-up for women, and some of this has been looked into, but we wanted to look at this a little bit further.  The use of Pap screen by Hispanic mothers has not been well examined in the context of psychological distress and/or depression.  And, again, using national data and being able to look at what is really the connection with this, and then also looking a little bit more on the issue of acculturation on preventative healthcare practices like Pap screening and service use among Hispanic mother has been studied but is still not yet well understood how that relates to why people have problems getting screened. 

So this study aims to understand a little bit more about the relationship between depressive symptoms or distress and years of being in the United States and language, so mental health and acculturation issues and how that impacts on the use of Pap screening among Hispanic mothers.  And the primary hypotheses that we had is that less time living in the United States and Spanish language, we would think as, you know, sort of barriers to care, will be associated with never having a Pap screen.  And, again, in this study, we looked at people who said that they had never had, not even just delayed screening but saying that they had never had screening.  Hispanic mothers with depressive symptoms, we also thought, would be more likely to report never having had Pap screening because of sort of the literature on women in general of having some difficulty getting to preventative care.  Just sort of a preliminary conceptual framework of how to think about this, basically, you know, we're looking at Latina mothers and that ethnicity and their ability to sort of get to the other side there, which is basically getting a Pap smear. 

And we believe that time in the United States itself might have an impact on this based on people being able to sort of access resources and understand how to get into resources that are healthcare related, which might even be combined or in addition to having other language and cultural barriers to be able to access care.  And we also thought that mental health status-- being in distress, being depressed, or even acculturative stress-- might also impact on people feeling comfortable accessing services so that these three things, in combination with insurance status and knowing how to get usual source of care, would impact on people being able to get Pap screening.  And, of course, insurance status would directly affect having usual source-- having access to usual source of care.  And insurance status, obviously, has been talked a lot about in the literature as being a barrier for this population, but we're wanting to look a little bit more at some of these mental health and acculturative things around getting Pap screening.  So the methods.  So it was a similar sample that *Whitney was talking about, it was a sample of mothers between the ages of 18 and 49, so reproductive age, and also in the 1998 National Health Interview Survey Adult Prevention Module.  And the ethnicities we looked at, we looked at Hispanic women, and we also looked at comparing to black African-American non-Hispanic women and other non-Hispanic. 

In that "other" population was a combination of people who sort of were not Hispanic and not fitting into the white non-Hispanics, so from people from other cultures, which was a smaller sampling in the data, and the reference group was white non-Hispanic.  And then the language, the best we could do with this survey is that we knew that if the person took the interview in Spanish or English, so that's not a perfect measure of that, but if the person took the interview in Spanish, we felt that they were more Spanish-dominant.  Again, we also looked at the maternal psychological distress and depressive symptoms using the-- some maternal depressive symptoms by-- six items of distress battery, which was by Kessler.  And it's correlated with the *SM4 defined depression.  And, again, we looked at similar things.  What *Whitney did was just basically looking at distressed score of seven out of possible 24 were considered having psychological distress. 

And the years of living in the United States, again, we thought of this as a measure of acculturation and potentially access, and there's been literature looking at acculturation as a problem with getting preventative care.  And we divided this into people who were born in the United States, people who've been here less than five years, five to 10 years, or greater than 10 years in the U.S.  We looked at whether people had-- mothers had any health insurance versus none and also usual source of care, which included having a regular source of a clinic, health center, doctor's office, or hospital outpatient department.  Now, Pap screening was available, and, again, people could report that they had never had a Pap screen, or they could report that they had delayed receipt of Pap screen, which was considered more than two years, based on recommendations. 

And then appropriate use of Pap screen was less than one year but not more than two years, so within the timeframe that is recommended by the medical profession.  And we modeled the odds of mothers never having a Pap screen and looked at it against mothers who received a Pap screen as recently as a year ago or less but not more than two years, so people who had delayed or appropriate, and we were looking at people who had never had.  The control variables-- again, we looked at age, education, live births within the past five years, as that might impact people on getting healthcare, single parent, poverty, and region of family residence to consider possible variations by region.  And the results are that, you know, we had these mothers between ages of 18 to 49, 70 percent were white, non-Hispanic; 14 percent black, non-Hispanic; 12 percent Hispanic; and 4 percent other, non-Hispanics.  And the Hispanics were-- sub-samples that included in the survey of NHIS was the Mexican-American group, Mexican origin, Puerto-Rican, Cuban, and other Latinos we put together, and this was-- there were several categories that people could fall into between Latin American and other Central American populations.  So in terms of looking at the sample, ethnicity characteristics and looking at the percent by Pap screen status, again, we focused on never having had a Pap screen.  But if you look at the Hispanics, 38 percent of the women there have reported that they had never had a Pap screen; 13 percent said they were delayed; and 12 percent, appropriate use of Pap. 

African-American women felt a little bit more into-- if you look sort of at the trend, at appropriate use, and then others never having had a Pap screen was another group that had high non-use.  And then whites, there was a significant that never had had but a good number of people who had appropriate use of Pap.  In terms of looking at Hispanic mothers not receiving Pap by depression distress status, having distress was a significant factor for all women, and the brown bar there sort of shows that even among everyone else, having depression or distress resulted in more of a percent of people not receiving Pap screening.  In general, with the Hispanic mothers, which is the orange bar there, this was also significant, but we're starting at sort of higher rates of people not using a Pap screen.  So 10 to 11-- around 11 percent of Hispanic mothers with distress had not received versus nine without distress or depression using the screener.  But one of the things that we found that was very significant is that the odds of never having had a Pap screen was very interesting when you looked at by time living in the United States.  So in the first sort of area there where it's less than five years, you know, 15-- women had a 15-- an odds ratio of 15 if they were here less than five years versus eight point four for people who were here five to 10 years and three point five for women who were 10-plus years in the United States.  And this was controlling for all the things that we talked about before, including insurance education, maternal age, all of those things, and still time in the U.S. was significant for all of these numbers. 

But you can see how much higher it is for women who were here less time.  One of the things that we did, also, is a staged model trying to look at how different things might impact on Hispanic women receiving-- you know, saying that they had never received a Pap screen, and you can see in our first model, we just basically looked at Hispanic ethnicity versus white, non-Hispanic as a reference point.  Hispanic woman had a six-point-three odds ratio of not ever having had a Pap screen by their report.  This went down significantly to two when you sort of considered how long people had been in the United States, so that had a great impact on that odds ratio.  Interestingly enough, when we added Spanish interview, we got an odds ratio of point seven, which we thought was surprising because it seemed that the women who had done the interview in Spanish had a less likelihood of saying that they never had had a Pap screen, and that was a surprising thing for us.  And I will talk a little bit more about that.  In terms of health-- and then we *then also put in health insurance coverage and usual source of care, and that affected the odds ratio for Hispanic woman, also, and then we had maternal depressive symptoms, and at that point, on the last line there, it was no longer significant after we controlled for all of those things for Hispanic women. 

But, again, the yellow here is significant, and the important thing here is also how-- the impact of time in the United States.  And our final model after, again, controlling for the things I've just said and then also insurance and, you know, I mean poverty threshold rather in region and all these other controls that we talked about, Hispanic was not significant any longer.  But the time in the U.S. was definitely still significant, and there was still a higher odds for other non-white populations, that other group that was a combination of different ethnicities.  Spanish language stayed significant, and somehow being lower, lower odds ratio of never having.  And, of course, having no usual source of care and maternal distress remained significant, too, as significant higher odds of never having a Pap screen.  So in the summary conclusions, after controlling for potential confounders, it seemed like less time living in the United States was highly associated with never having Pap screen among mothers, and this was not necessarily specific for Hispanic women either.  We saw that relationship for the other groups, including that other non-white population.  That had quite an influence on that group as well.  Mothers living in the U.S. less than five years are 15 times more likely to say that they never had a Pap screen than those born in the United States, and psychological distress remained an important association with not ever having Pap screening among mothers and Hispanic mothers as well. 

Women who were interviewed in Spanish were less likely to report that they have never had a Pap screen, and we did find that to be a very interesting finding because we would think that would be a barrier to getting healthcare.  And after looking extensively in the literature and also looking at our sample a little bit about who was speaking Spanish, there were definitely different groups in our population that were more likely to do a Spanish interview, and some of those, for example, was our Cuban population, which, when you look at other things of that population, they seem to have a higher access to healthcare.  The other population that had a lot of Spanish interview was the Mexican origin population, and it's not clear whether they had had better care before coming here and now they're having barriers to getting care now in the United States, so there seems to be something different about that population because those were definitely the largest populations that were speaking Spanish in our sample, more than Puerto Ricans or the Mexican-Americans.  So we believe that language has been implicated as a barrier to preventative care for Hispanic women obviously, but it may have a differential impact for different groups, and variations in healthcare, health-seeking resources, for example, like in the Cuban-American population social networks, and also complex cultural factors that are very specific to different groups may contribute to this variation, and I think that's one of the things we want to look at a little closer in the future. 

Again, some of the limitations of this study are obviously, as usual, it's a cross-sectional data, so we can't talk about, you know, causations, and the other thing is that it's a very imprecise measure of English language proficiency, which was one of the key things we wanted to look at, and social cultural factors.  I mean they're sort of not very precise in trying to figure out where people really are in the acculturation level or, you know, why they're taking the interview in Spanish or English and is that really a marker of proficiency or acculturation.  Some of the strengths are that it is a national representative data of mothers and Hispanic mothers, so we were able to look at some of these associations that people have looked at in smaller studies and that we had a-- you know, and this is a big deal, I think, as a psychiatrist.  I always say this, that there was a validated measure of psychological distress that has really been correlated with depression and anxiety so that we can really try to measure some mental health component among mothers. 

So some of the policy implications I think we should consider is I think it's important to look a little bit more into this idea of promoting and ensuring access to usual source of care in healthcare coverage, especially for immigrants soon after immigration and not sort of causing this lag or delay of being able to access care; as usual, providing cultural-appropriate education outreach, especially among recent-- the immigrant mothers because that seems to be a population that is not receiving these services; and to also address mental health as a correlative non-use of Pap screening among mothers and considering that in our inter-interventions and treatment.  But the other thing that I think, which is something that we want to look at more, is that, you know, there is a need for nationally representative ethnic-specific research, which can, you know, promote the advancement of measures and data collection for this purpose. 

For example, having more precise ideas about people's acculturation levels and socio-cultural factors that might impact people accessing services, including preventative care.  And it would be great to have that more in the national databases.  So that's it.