Design and pilot testing of a church-based intervention to address interpersonal and intrapersonal barriers to uptake of family planning in rural Tanzania: a qualitative implementation study

BACKGROUND

Use of family planning (FP) saves the lives of mothers and children, and contributes to better economic outcomes for households and empowerment for women. In Tanzania, the overall unmet need for FP is high. This study aimed: (1) to use focus group data to construct a theoretical framework to understand the multidimensional factors impacting the decision to use FP in rural Tanzania; (2) to design and pilot-test an educational seminar, informed by this framework, to promote uptake of FP; and (3) to assess acceptability and further refine the educational seminar based on focus group data collected 3 months after the education was provided.

METHODS

We performed a thematic analysis of 10 focus group discussions about social and religious aspects of FP from predominantly Protestant church attenders prior to any intervention, and afterwards from six groups of church leaders who had attended the educational seminar.

RESULTS

Key interpersonal influences included lack of support from husband/partner, family members, neighbours and church communities. Major intrapersonal factors impeding FP use were lack of medical knowledge and information, misconceptions, and perceived incompatibility of FP and Christian faith. Post-seminar, leaders reported renewed intrapersonal perspectives on FP and reported teaching these perspectives to community members.

CONCLUSIONS

Addressing intrapersonal barriers to FP use for leaders led them to subsequently address both intrapersonal and interpersonal barriers in their church communities. This occurred primarily by increasing knowledge and support for FP in men, family members, neighbours and church communities.

Maternal Emotional and Physiological Reactivity: Implications for Parenting and the Parenting-Adolescent Relationship

OBJECTIVE

Parent physiology and emotion may play an important role in parenting and parent-child relationship quality, yet little research has examined these associations in parents of adolescents. This study employed a naturalistic laboratory-based approach to observe maternal reactivity (mothers' cardiovascular and negative emotional responses) during a parent-adolescent interaction task (PAIT) and associations with parenting behavior and parent-adolescent relationship quality. We also examined possible indirect effect of maternal reactivity on parent-adolescent relationship quality through parenting variables.

METHODS

Mothers (n = 196) of 12-14 year olds completed the PAIT, a 10-minute laboratory task in which mothers and adolescents discussed a family conflict topic. Mother-rated negative emotional experience, mother heart rate (HR), and systolic and diastolic blood pressure (BP) responses to PAIT were collected. Additionally, observed maladaptive and positive parenting during PAIT and reported parent-adolescent relationship quality were collected.

RESULTS

We found that mothers' heightened negative emotional experience in PAIT was associated with heightened observed and reported maladaptive parenting and lower parent-adolescent relationship quality (p<.001). Additionally, blunted HR reactivity was related to higher positive parenting in PAIT (p<.05). Lastly, we found an indirect effect of HR on parent-adolescent relationship through positive parenting and an indirect effect of maternal negative emotional experience on parent-adolescent relationship quality through maladaptive and positive parenting. In sum, high emotional reactivity and blunted HR predicted poorer parenting, and directly and indirectly affected parent-adolescent relationship quality.

CONCLUSIONS

Parent reactivity may be important to consider in interventions.

Psychological distress, health protection, and sexual practices among young men who have sex with men: Using social action theory to guide HIV prevention efforts

The present study addresses gaps in the literature related to theory development for young men who have sex with men (YMSM) sexual practices through the application and modification of Social Action Theory. Data come from the Healthy Young Men study (N = 526), which longitudinally tracked a diverse cohort of YMSM ages 18–24 to characterize risk and protective factors associated with drug use and sexual practices. Structural equation modeling examined the applicability of, and any necessary modifications to a YMSM-focused version of Social Action Theory. The final model displayed excellent fit (CFI = 0.955, TLI = 0.947, RMSEA = 0.037) and suggested concordance between social support and personal capacity for sexual health promotion. For YMSM, practicing health promotion and avoiding practices that may put them at risk for HIV was associated with both social isolation and psychological distress (β = -0.372, t = -4.601, p<0.001); psychological distress is an internalized response to environmental and cognitive factors and sexual practices are an externalized response. Results point to the utility of Social Action Theory as a useful model for understanding sexual practices among YMSM, the application of which shows health protective sexual practices are a function of sociocognitive factors that are influenced by environmental contexts. Social Action Theory can help prevention scientists better address the needs of this vulnerable population.

Cumulative Risk and Physiological Stress Responses in African American Adolescents

OBJECTIVE

To investigate associations between components of cumulative risk (CR) and physiological stress responses in African American adolescents and evaluate emotion regulation as a mediator and sex as a moderator of these associations.

METHODS

Cortisol and salivary alpha amylase (sAA) were collected in adolescents ( N = 205; 55% female; 12.1 ± 1.6 years at baseline) as part of a longitudinal study of stress and adjustment in families. CR was assessed at baseline and emotion regulation was assessed at baseline and 2 years later at Wave 3 (W3) using caregiver and adolescent reports. Cortisol and sAA responses to the social competence interview were assessed at W3.

RESULTS

Repeated-measures analyses of variance predicting cortisol and controlling for time of day, adolescent age, medication usage, and pubertal status revealed significant interactions of time with both psychosocial and sociodemographic risk. In both analyses, youths with higher levels of risk showed a steeper decline in cortisol than youths with lower levels of risk. In parallel analyses predicting sAA, time interacted with psychosocial but not with sociodemographic risk. There were no interactions with sex in any of the analyses. Although CR was associated with changes in emotion regulation, there was no evidence that these changes accounted for the observed CR-stress response associations.

CONCLUSIONS

These findings illustrate the potential importance of disentangling CR and suggest that additional work is needed to help explicate why and how CR is associated with specific physiological responses to stress.

Victimization and Biological Stress Responses in Urban Adolescents: Emotion Regulation as a Moderator

Associations between urban adolescents' victimization experiences and biological stress responses were examined, as well as emotion regulation as a moderator of these associations. Data from a 4-wave longitudinal study with a low-income, community-based sample (n = 242; 91 % African American; 57 % female; M = 11.98, SD = 1.56 years at baseline) revealed that victimization, assessed over 3 study waves, was associated with an attenuated cortisol response to a stress interview at the final study wave, indicating that responses of the Hypothalamus-Pituitary-Adrenal (HPA) axis were dysregulated. Cortisol responses were moderated by caregiver-reported adolescent emotion regulation, suggesting that this modifiable protective factor that is taught in many school-based prevention programs could help reduce harm associated with HPA axis dysregulation linked to victimization.

Central nervous system influences in asthma

Asthma is a biomedical disorder whose presentation can be markedly influenced by neurological and psychological factors. This chapter describes several approaches that provide insight into the role of psychological factors and brain function in asthma. These include the study of placebo responses and recent explorations using functional neuroimaging during the onset of asthma symptoms. Although the specific mechanisms involved remain uncertain, we are gaining an appreciation for some of the neurocircuitry that is involved. The insula and ACC may modulate inflammatory processes by their influence on neuroendocrine responses to stress, including highly studied effects on the HPA axis and its physiologic responses. However much we have recently learned, it is clear that further study of this topic is critical to fully explicate the role of the brain in asthma.

Codevelopment of externalizing and internalizing symptoms in middle to late childhood: sex, baseline respiratory sinus arrhythmia, and respiratory sinus arrhythmia reactivity as predictors

We investigated the roles of sex and respiratory sinus arrhythmia (RSA), an index of autonomic parasympathetic nervous system activity, as predictors of codeveloping externalizing and internalizing symptoms in middle childhood. We expected that sex, baseline RSA (RSA-B), and RSA reactivity (RSA-R) to two types of tasks would interact to differentiate co-occurring trajectories of symptoms. We tested these hypotheses by combining longitudinal data from two independent samples (n = 390; 210 girls, 180 boys) with repeated measures at ages 8, 9, 10, and 11. RSA-R was measured in response to a socially stressful and frustrating stressor. Indicators of growth in externalizing and internalizing symptoms were derived from multiple domain growth models and used in person-centered growth mixture analyses. Three groups of externalizing and internalizing trajectories were found. Profile membership was predicted by several two-way interactions among sex, RSA-B, or RSA-R but was not predicted by three-way interactions. Children with low RSA-B and strong RSA withdrawal, girls with low RSA-B, and girls with strong RSA withdrawal were more likely to be on a developmental trajectory of low externalizing symptoms and moderately elevated internalizing symptoms. Membership in the high externalizing and high internalizing trajectory was predicted by weak RSA withdrawal for boys and strong RSA withdrawal for girls. The type of stressor task also played a role in predicting probability of profile membership. Results are discussed in the context of developmental psychobiology and implications for the codevelopment of psychopathology symptoms in childhood.

How can the study of physiological reactivity contribute to our understanding of adversity and resilience processes in development?

The focus of this article is to present current progress in understanding the interplay among adversity, physiological sensitivity to context, and adaptive functioning, with an emphasis on implications and future directions for resilience researchers. It includes a review of current literature that demonstrates (a) links between various levels of adversity exposure and variability in physiological reactivity, (b) how the interplay between children's physiological reactivity and different sources of risk and adversity relates to variability in adaptive functioning, and (c) various approaches for capturing a more dynamic nature of physiological reactivity and related processes. Throughout, important conceptual and empirical issues are highlighted.

Physiological correlates of peer victimization and aggression in African American urban adolescents

This study examined physiological correlates (cortisol and α-amylase [AA]) of peer victimization and aggression in a sample of 228 adolescents (45% male, 55% female; 90% African American; M age = 14 years, SD = 1.6 years) who participated in a longitudinal study of stress, physiology, and adjustment. Adolescents were classified into victimization/aggression groups based on patterns with three waves of data. At Wave 3, youth completed the Social Competence Interview (SCI), and four saliva samples were collected prior to, during, and following the SCI. Repeated-measures analyses of variance with victimization/aggression group as the predictor, and physiological measures as outcomes, controlling for time of day, pubertal status, and medication use revealed significant Group × SCI Phase interactions for salivary AA (sAA), but not for cortisol. The results did not differ by sex. For analyses with physical victimization/aggression, aggressive and nonaggressive victims showed increases in sAA during the SCI, nonvictimized aggressors showed a decrease, and the normative contrast group did not show any change. For analyses with relational victimization/aggression, nonaggressive victims were the only group who demonstrated sAA reactivity. Incorporating physiological measures into peer victimization studies may give researchers and clinicians insight into youth's behavior regulation, and help shape prevention or intervention efforts.

Theory development for HIV behavioral health: empirical validation of behavior health models specific to HIV risk

In the presence of numerous health behavior theories, it is difficult to determine which of the many theories is most precise in explaining health-related behavior. New models continue to be introduced to the field, despite already existing disparity, overlap, and lack of unification among health promotion theories. This paper will provide an overview of current arguments and frameworks for testing and developing a comprehensive set of health behavior theories. In addition, the authors make a unique contribution to the HIV health behavior theory literature by moving beyond current health behavior theory critiques to argue that one of the field's preexisting, but less popular theories, Social Action Theory (SAT), offers a pragmatic and broad framework to address many of the accuracy issues within HIV health behavior theory. The authors conclude this article by offering a comprehensive plan for validating model accuracy, variable influence, and behavioral applicability of SAT.

Differentiating challenge reactivity from psychomotor activity in studies of children's psychophysiology: considerations for theory and measurement

Current methods of assessing children's physiological "stress reactivity" may be confounded by psychomotor activity, biasing estimates of the relation between reactivity and health. We examined the joint and independent contributions of psychomotor activity and challenge reactivity during a protocol for 5- and 6-year-old children (N = 338). Measures of parasympathetic reactivity (respiratory sinus arrhythmia [RSA]) and sympathetic reactivity (preejection period [PEP]) were calculated for social, cognitive, sensory, and emotional challenge tasks. Reactivity was calculated relative to both resting and a paired comparison task that accounted for psychomotor activity effects during each challenge. Results indicated that comparison tasks themselves elicited RSA and PEP responses, and reactivity adjusted for psychomotor activity was incongruent with reactivity calculated using rest. Findings demonstrate the importance of accounting for confounding psychomotor activity effects on physiological reactivity.

Marital conflict, respiratory sinus arrhythmia, and allostatic load: interrelations and associations with the development of children's externalizing behavior

Allostatic load theory hypothesizes that stress and the body's responses to stressors contribute to longer term physiological changes in multiple systems over time (allostasis), and that shifts in how these systems function have implications for adjustment and health. We investigated these hypotheses with longitudinal data from two independent samples (n = 413; 219 girls, 194 boys) with repeated measures at ages 8, 9, 10, and 11. Initial parental marital conflict and its change over time indexed children's exposure to an important familial stressor, which was examined in interaction with children's respiratory sinus arrhythmia (RSA) reactivity to laboratory tasks (stress response) to predict children's basal levels of RSA over time. We also investigated children's sex as an additional possible moderator. Our second research question focused on examining whether initial levels and changes in resting RSA over time predicted children's externalizing behavior. Boys with a strong RSA suppression response to a frustrating laboratory task who experienced higher initial marital conflict or increasing marital conflict over time showed decreases in their resting RSA over time. In addition, boys' initial resting RSA (but not changes in resting RSA over time) was negatively related to change over time in externalizing symptoms. Findings for girls were more mixed. Results are discussed in the context of developmental psychobiology, allostatic load, and implications for the development of psychopathology.

The interactive effect of marital conflict and stress reactivity on externalizing and internalizing symptoms: the role of laboratory stressors

Growing evidence supports the biological sensitivity to context theory, which posits that physiologically reactive children, as indexed by autonomic nervous system (ANS) reactivity to laboratory stressors, are more susceptible to both negative and positive environmental influences than their low reactive peers. High biological sensitivity is a risk factor for behavioral and health problems in the context of high adversity, whereas in contexts of low adversity it has been found to promote positive adaptation. However, several studies have shown the opposite effect, finding that children who exhibited high ANS reactivity in response to interpersonal stressors were buffered from the deleterious effects of marital conflict, whereas children who showed low ANS reactivity were more vulnerable to high levels of marital conflict. Using an ethnically diverse sample of 260 kindergartners (130 girls, 130 boys), the current study investigated whether the interaction effect of marital conflict and the two branches of ANS reactivity on children's externalizing and internalizing symptoms differs with the nature of the laboratory challenge task used to measure children's stress response. As hypothesized, results indicate that the interaction between ANS reactivity and marital conflict significantly predicted children's behavior problems, but the direction of the effect varied with the nature of the challenge task (i.e., interpersonal or cognitive). This study illustrates the importance of considering the effect of laboratory stimuli when assessing whether children's ANS reactivity moderates the effects of adversity exposure on adaptation.

Use of the social competence interview and the anger transcendence challenge in individuals with alcohol use disorder

Interpersonal stress is a significant determinant of relapse following treatment for Alcohol Use Disorders (AUDs), but there remains little specific information about the mechanisms underlying the relationship between interpersonal stress and AUD relapse. Application of Social Action Theory provides one new approach to advancing knowledge about the interpersonal stress-relapse relationship. Especially relevant are the Social Action Theory construct of social-emotional competence, with its accompanying measurement procedures of the Social Competence Interview and the Anger Transcendence Challenge. This study evaluated the use of the Social Competence Interview and Anger Transcendence Challenge in a sample of 63 men and women in AUD intensive outpatient treatment. The results support the use of the Social Competence Interview and the Anger Transcendence Challenge with an adult AUD clinical sample, so that these measures may help to advance knowledge about the relationship between interpersonal stress and alcohol relapse.

Stress response and the adolescent transition: performance versus peer rejection stressors

Little is known about normative variation in stress response over the adolescent transition. This study examined neuroendocrine and cardiovascular responses to performance and peer rejection stressors over the adolescent transition in a normative sample. Participants were 82 healthy children (ages 7-12 years, n = 39, 22 females) and adolescents (ages 13-17, n = 43, 20 females) recruited through community postings. Following a habituation session, participants completed a performance (public speaking, mental arithmetic, mirror tracing) or peer rejection (exclusion challenges) stress session. Salivary cortisol, salivary alpha amylase (sAA), systolic and diastolic blood pressure (SBP, DBP), and heart rate were measured throughout. Adolescents showed significantly greater cortisol, sAA, SBP, and DBP stress response relative to children. Developmental differences were most pronounced in the performance stress session for cortisol and DBP and in the peer rejection session for sAA and SBP. Heightened physiological stress responses in typical adolescents may facilitate adaptation to new challenges of adolescence and adulthood. In high-risk adolescents, this normative shift may tip the balance toward stress response dysregulation associated with depression and other psychopathology. Specificity of physiological response by stressor type highlights the importance of a multisystem approach to the psychobiology of stress and may also have implications for understanding trajectories to psychopathology.

Trajectories of maternal depressive symptoms over her child's life span: relation to adrenocortical, cardiovascular, and emotional functioning in children

Maternal depression has a number of adverse effects on children. In the present study, maternal depressive symptoms were assessed (using the Center for Epidemiological Studies Depression Scale) when their child was 3 months, 6 months, 1 year, 2 years, 4.25 years, 6 years, 7 years, 8 years, and 10 years of age. At 9.5 years of age, children's (94 females, 82 males) depressive symptoms as well as cardiovascular and cortisol levels during baseline and two psychologically stressful tasks were measured. Using multilevel modeling, maternal depressive symptom trajectories were considered in relation to their child's adrenocortical and cardiovascular responses to acute stress. Our goal was to determine maternal depressive symptom trajectories for children with elevated cardiovascular and cortisol reactivity to acute stress and elevated depressive symptoms. In general, those mothers with chronically elevated depressive symptoms over their child's life span had children with lower initial cortisol, higher cardiac output and stroke volume in response to acute stress, lower vascular resistance during acute stress tasks, and significantly more depressive symptoms at 9.5 years of age. These results are discussed in the context of established associations among hypothalamic-pituitary-adrenal axis dysregulation, depression, and cardiovascular disease.

Examining the stress response and recovery among children with migraine

OBJECTIVE

This study compared physiological differences between children diagnosed with migraine and their healthy peers.

METHOD

Physiological measures were obtained at baseline, after discussing an emotional stressor, and after a 5-min recovery period in 21 children with pediatric migraine and 32 healthy peers. Comparisons were also made on psychological measures investigating anxiety.

RESULTS

Children with migraine exhibited a significantly higher pulse rate compared to comparison children at rest, and higher diastolic blood pressure and higher low-frequency/high-frequency ratio after a 5-min recovery from an emotional stressor. Additionally, when anxiety was entered as a covariate, group differences after the 5-min recovery period were no longer significant.

CONCLUSIONS

Results suggest that relative to comparison children, children with migraine exhibit some physiological elevation at rest, as well as a prolonged physiological recovery period after an emotional stressor. Group differences after the 5-min recovery period suggest that children with migraine experience delayed sympathetic hyperarousal and prolonged sympathovagal imbalance. The treatment implications of these findings are discussed.

Effects of mothers' prenatal psychiatric status and postnatal caregiving on infant biobehavioral regulation: can prenatal programming be modified?

BACKGROUND

Animal research suggests that antenatal stress exposure and postnatal rearing style act in concert to shape offspring biobehavioral outcomes. However, the combination of these maternally-mediated influences has not been studied in human infants.

AIMS

To examine antenatal psychiatric status and maternal sensitivity in relation to 4-month-olds' autonomic regulation, HPA-axis functioning, and behavior.

STUDY DESIGN

Prospective study of 47 pregnant women recruited from an urban hospital who completed questionnaire measures of anxiety and depression and underwent a psychiatric interview in the 2nd trimester. At 4 months postpartum, women again completed mood questionnaires and the mother-infant dyads participated in a 10-minute free-play session evaluated for maternal sensitivity.

OUTCOME MEASURES

Baseline infant salivary cortisol and electrocardiogram (EKG) collected at the start of the 4-month sessions. Infant responsiveness and maternal report of temperament also were evaluated.

RESULTS

Maternal sensitivity, but not antenatal psychiatric diagnosis, predicted greater levels of infant high frequency heart rate variability, after controlling for birth weight and age. Maternal sensitivity, but not psychiatric status, also predicted infant responsiveness. Maternal sensitivity modulated the effects of psychiatric illness on infant cortisol such that cortisol was low regardless of sensitivity for children of healthy women yet higher if the infant had insensitive versus sensitive caregiving when the mother had had an antenatal diagnosis.

CONCLUSIONS

Biobehavioral adaptation, even that initiated in utero, is influenced by interactions with the social world. These findings support the compatibility of fetal programming and social-context models of infant biobehavioral development and have promising implications for pre and postnatal clinical intervention.

Stress and blood pressure during pregnancy: racial differences and associations with birthweight

OBJECTIVE

To extend findings that African American women report greater stress during pregnancy, have higher blood pressure (BP), and are twice as likely to have low birthweight infants relative to white women. This study examines a) racial differences in associations between stress and BP during pregnancy, and b) the combined effects of stress and BP on infant birthweight in a sample of 170 African American and white women.

METHODS

A prospective, longitudinal study of pregnant women was conducted in which measures of BP, stress, and other relevant variables were collected. Multiple measures of systolic and diastolic BP were taken at each of three points during pregnancy (18-20, 24-26, and 30-32 weeks gestation).

RESULTS

Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were positively associated with stress in pregnant African American women and not in pregnant white women. In analyses of birthweight, there were no main effects of BP or stress. However, a significant interaction demonstrated that, when stress was high, DBP was negatively associated with birthweight and a combination of high stress and high DBP predicted the lowest birthweight in the sample. Furthermore, African American women were twice as likely as white women to have a combination of high stress and high DBP.

CONCLUSIONS

Racial differences in relationships between stress and BP, and the interactive effect of stress and DBP on birthweight together suggest that a high stress-high BP profile may pose a risk for lower birthweight among African American women, in particular, and possibly for all pregnant women.

Social relationships and physiological function: the effects of recalling social relationships on cardiovascular reactivity

BACKGROUND

The mechanisms by which social relationships exert their influence on mental and physical health outcomes deserve greater attention.

PURPOSE

Although many studies assess the influence of actual social interactions on cardiovascular reactivity, we hypothesized that cognitive and behavioral processes (e.g., recalling and discussing relationships) may be important factors responsible for the health effects of social relationships.

METHODS

We had men and women recall and speak about specific relationships that differed in their underlying positive and negative substrates.

RESULTS

Results revealed that gender moderated the hypothesized pattern of responses, with women showing consistently greater cardiovascular reactivity to the speaking task, particularly when speaking about negative relationships, compared to men.

CONCLUSIONS

This study is discussed in light of recent research on gender differences in relationship outcomes as well as the potential importance of delineating the cognitive representations and processes that influence reactions to one's social environment.

The relationship between exposure to violence and blood pressure mechanisms

Although previous research has indicated a link between environmental stress and essential hypertension, little is known about the role of violence exposure on risk for developing essential hypertension. Violence exposure, defined as experiencing, witnessing, or hearing about violence in the home, school, or neighborhood, is a serious societal problem. Approximately 70% of inner-city youth have been victims of violent acts, and approximately 85% of these youths report having witnessed violent acts. In this review, several possible paths are proposed to explain the link between exposure to violence and cardiovascular health outcomes (eg, physiologic and psychosocial). Several contextual models are outlined, and a review of the empirical evidence suggests that chronic environmental stress (eg, violence exposure) might play a role in the development of essential hypertension. The mechanisms underlying the effects of violence exposure on blood pressure are unknown, although preliminary evidence suggests that elevated sympathetic nervous system activity may be involved. Several possible psychosocial mechanisms are outlined that might also link violence exposure to physiologic blood pressure-related mechanisms. Prevention and intervention efforts to reduce community violence are reviewed, and a call is made for encouraging further research on this critical topic.

Agonistic Interpersonal Striving: Social-Cognitive Mechanism of Cardiovascular Risk in Youth?

The social competence model (SCM) of cardiovascular disease (CVD) risk identifies combinations of goal-oriented strivings, expressive behaviors, and social skill deficits that contribute to persisting interpersonal difficulties and chronic health-damaging stress in youth. SCM hypotheses were tested on 187 Black and White adolescents who completed the Social Competence Interview (SCI) and later underwent ambulatory blood pressure (ABP) monitoring. Cluster analyses of stress narratives assessed via SCI identified 3 predicted stress profiles: agonistic (interpersonally focused), transcendent (self-development focused), and avoidant. Group comparisons using social, hemodynamic, and ABP data supported the SCM hypothesis that youths who exhibit the agonistic striving profile display diminished social competence, negative social impact, and heightened cardiovascular responding during a stress interview, and elevated ABP during normal social interactions, thus suggesting higher risk of CVD.