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

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

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

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%

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

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

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

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

A Biopsychosocial ModelA Biopsychosocial Model

Neuroendocrine Neuroendocrine systemsystem

Immune Immune systemsystem

Cardiovascular Cardiovascular systemsystem

STRESSSTRESSBirth Birth

outcomesoutcomes

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

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

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

RACISM AND ADVERSE RACISM AND ADVERSE

PREGNANCY OUTCOMESPREGNANCY OUTCOMES

A Program of ResearchA Program of Research

• 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

STUDY 1

Does stress mediate racial differences in birth outcomes?

Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2005

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

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?

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+

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*

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

STUDY 2Are there physiological

factors that link racism

to birth outcomes?

Parker Dominguez, Hilmert, Dunkel Schetter, Glynn, Sandman, & Hobel, 2005

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

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

Racism, NE Function and BW

Vicarious Childhood Exposure

+CRH 34-36 weeks Birthweight

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*

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

STUDY 3Are there differences across

multiple racial/ethnic groups in

exposure to and impact of racism?

Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004

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

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

DISTRESSDISTRESS

AfrAms and Latinas were significantly less distressed than APIs and Whites

RESPONSERESPONSE

•AfrAms significantly more likely to keep racism experiences to themselves

•AfrAms significantly more likely to accept unfair treatment as a fact of life

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

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

Interaction EffectsInteraction Effects

= .22, p < .05

APIs: = .07, p > .10

AfrAms: = -.36, p < .05

Racism and BW

African Americans X APIs

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

Improved racism measures Improved racism measures

Multi-level studiesMulti-level studies

Lifespan Approach Lifespan Approach

CBPRCBPR

Interdisciplinary teamsInterdisciplinary teams

Looking ahead…..

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