Tyan Parker Dominguez, PhD, MPH, MSW School of Social Work University of Southern California
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Transcript of Tyan Parker Dominguez, PhD, MPH, MSW School of Social Work University of Southern California
Tyan Parker Dominguez, PhD, MPH, MSWTyan Parker Dominguez, PhD, MPH, MSWSchool of Social WorkSchool of Social Work
University of Southern CaliforniaUniversity of Southern California
BIOPSYCHOSOCIAL CONTRIBUTORS BIOPSYCHOSOCIAL CONTRIBUTORS
TO RACIAL DISPARITIES IN TO RACIAL DISPARITIES IN
ADVERSE BIRTH OUTCOMESADVERSE BIRTH OUTCOMES
1) Discuss stress paradigm and links to 1) Discuss stress paradigm and links to adverse health outcomesadverse health outcomes
2) Describe ethnic differences in 2) Describe ethnic differences in lifetime exposure and impact on lifetime exposure and impact on outcomes in pregnancy outcomes in pregnancy
3) Identify physiological mechanisms3) Identify physiological mechanisms
OBJECTIVESOBJECTIVES
African-Americans have the highest infant mortality rate and the highest rates of low birthweight and preterm delivery of all
racial and ethnic groups in this country
Persistent Racial Disparity
• In childhood:In childhood:Cerebral palsy, epilepsy, chronic lung disease, Cerebral palsy, epilepsy, chronic lung disease, deafness, blindness, ADHD, cognitive deficits, deafness, blindness, ADHD, cognitive deficits, learning disabilitieslearning disabilities
• In adulthood:In adulthood:Cardiovascular disease, diabetes, hypertensionCardiovascular disease, diabetes, hypertension(Barker thesis)(Barker thesis)
RELATED SEQUELAERELATED SEQUELAE
INFANTINFANT
• BirthweightBirthweight• Gestational age Gestational age • Fetal GrowthFetal Growth
• Gestational ageGestational age
MOTHERMOTHER
• BirthweightBirthweight
• Gestational ageGestational age
Intergenerational Perpetuation of RiskIntergenerational Perpetuation of Risk
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
diseasediseaseCohen, Kessler, & Gordon, 1995Cohen, Kessler, & Gordon, 1995
BirthweightBirthweight
Gestational lengthGestational length
Stressful life eventsStressful life events
Events distressEvents distress
Perceived stressPerceived stress
State anxietyState anxiety
Pregnancy anxietyPregnancy anxiety
THE EVIDENCETHE EVIDENCE
African-Americans face greater and more African-Americans face greater and more
severe stressors earlier in life, encounter them severe stressors earlier in life, encounter them
more frequently, and perceive these events as more frequently, and perceive these events as
more stressful than do other groupsmore stressful than do other groups
Askenasy, Dohrenwend, & Dohrenwend, 1977; Askenasy, Dohrenwend, & Dohrenwend, 1977; Dohrenwend, 1973; Feldman, Dunkel-Schetter, Woo & Dohrenwend, 1973; Feldman, Dunkel-Schetter, Woo &
Hobel, 1997; Myers, 1982; Zambrana et al., 1999 Hobel, 1997; Myers, 1982; Zambrana et al., 1999
A Biopsychosocial ModelA Biopsychosocial Model
Neuroendocrine Neuroendocrine systemsystem
Immune Immune systemsystem
Cardiovascular Cardiovascular systemsystem
STRESSSTRESSBirth Birth
outcomesoutcomes
NeuroendocrineNeuroendocrineSystemSystem
Placental CRH controls placental clockPlacental CRH controls placental clock
Maternal stress maternal CRH, ACTH, Maternal stress maternal CRH, ACTH,
cortisol releasedcortisol released
Triggers additional CRH expression in placentaTriggers additional CRH expression in placenta
THE HPA AXISTHE HPA AXIS
Elevated levels of CRH significantly related to…Elevated levels of CRH significantly related to…
• PRETERM LABOR PRETERM LABOR (Korebritis et al, 1998; Wadhwa et al, (Korebritis et al, 1998; Wadhwa et al, 1998)1998)
• PRETERM DELIVERY PRETERM DELIVERY (Hobel et al, 1999; McLean et al, (Hobel et al, 1999; McLean et al, 1995; Wadhwa et al, 2004)1995; Wadhwa et al, 2004)
• FETAL GROWTH RESTRICTION FETAL GROWTH RESTRICTION (Wadhwa et al, (Wadhwa et al, 2004)2004)
independent of medical riskindependent of medical risk
ImmuneImmuneSystemSystem
Paternal antigens immunosuppressionPaternal antigens immunosuppression
Stress immunosuppressionStress immunosuppression
Infection major risk factor for PTDInfection major risk factor for PTD
BV most common; AfrAms highest prevalenceBV most common; AfrAms highest prevalence
Proinflammatory cytokines promote placental CRH Proinflammatory cytokines promote placental CRH
expressionexpression
INFECTIONINFECTION
High maternal stress significantly associated with…High maternal stress significantly associated with…
• DEPRESSED LYMPHOCYTE ACTIVITY DEPRESSED LYMPHOCYTE ACTIVITY (Herrera et al, 1998)(Herrera et al, 1998)
• BACTERIAL VAGINOSIS BACTERIAL VAGINOSIS (Culhane et al, 2001)(Culhane et al, 2001)
independent of confoundersindependent of confounders
CardiovascularCardiovascularSystemSystem
Stress cardiovascular disordersStress cardiovascular disorders
Preg-induced hypertension and preeclampsia Preg-induced hypertension and preeclampsia
Major risk factors for PTDMajor risk factors for PTD Significantly elevated CRH levels Significantly elevated CRH levels (Jeske et al, 1990; (Jeske et al, 1990;
Perkins et al, 1995; Warren et al, 1995)Perkins et al, 1995; Warren et al, 1995)
HYPERTENSIVE DISORDERSHYPERTENSIVE DISORDERS
• Elevated CRH related to abnormal Elevated CRH related to abnormal UTEROPLACENTAL BLOOD FLOW UTEROPLACENTAL BLOOD FLOW (Giles et al, (Giles et al, 1996)1996)
• DBP REACTIVITY to stressor task predicted DBP REACTIVITY to stressor task predicted gestational length and infant birthweight gestational length and infant birthweight (McCubbin (McCubbin et al, 1996)et al, 1996)
• Maternal anxiety associated with PULSATILITY Maternal anxiety associated with PULSATILITY INDEX INDEX (Sjostrom et al, 1997; Teixeria et al, 1999)(Sjostrom et al, 1997; Teixeria et al, 1999)
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
Few groups, if any, have experienced Few groups, if any, have experienced
for so long the kind and degree of for so long the kind and degree of
discrimination that US-born Blacks discrimination that US-born Blacks
have faced.have faced.
- Singh & Yu, 1996- Singh & Yu, 1996
. . . a likely fundamental cause of the. . . a likely fundamental cause of the
nations’s enduring racial/ethnic nations’s enduring racial/ethnic
disparities in health disparities in health
- James, 2003- James, 2003
RACISMRACISM
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
• WeatheringWeathering (Geronimus, 1992)(Geronimus, 1992)
• as African-American women aged, their risk of as African-American women aged, their risk of delivering a low birthweight infant delivering a low birthweight infant significantly increased significantly increased
• Socioeconomic status moderated the effectSocioeconomic status moderated the effect
• Relationship not evident in White women Relationship not evident in White women
• accelerated decline in health statusaccelerated decline in health status in response in response to the cumulative effects of social inequalityto the cumulative effects of social inequality
Physiological Impact of InequalityPhysiological Impact of Inequality
• AfrAms show heightened & AfrAms show heightened & prolonged cardiovascular reactivity prolonged cardiovascular reactivity to racist stimulito racist stimuli (Armstead et al, 1989; Guyll et al, 2001)(Armstead et al, 1989; Guyll et al, 2001)
• Hypertension = cardiovascular dysregulation Hypertension = cardiovascular dysregulation caused by hyperreactivity to stresscaused by hyperreactivity to stress (Manuck, (Manuck, Kasprowicz, & Muldoon, 1990Kasprowicz, & Muldoon, 1990)
• AfrAms highest rates of general hypertension, AfrAms highest rates of general hypertension, hypertensive disorders in pregnancyhypertensive disorders in pregnancy
Physiological Impact of RacismPhysiological Impact of Racism
• AfrAms report PTSD-like symptomsAfrAms report PTSD-like symptoms (Thompson, 1996)(Thompson, 1996)
• PTSD associated w/ HPA axis dysregulationPTSD associated w/ HPA axis dysregulation
• Evident in AfrAm adolescent girls and Evident in AfrAm adolescent girls and pregnant womenpregnant women
Physiological Impact of RacismPhysiological Impact of Racism
Are there ethnic differences in perceived Are there ethnic differences in perceived lifetime exposure to racism events?lifetime exposure to racism events?
Are there ethnic differences in the impact Are there ethnic differences in the impact of racism on psychosocial functioning?of racism on psychosocial functioning?
Are there ethnic differences in the impact Are there ethnic differences in the impact of racism on birth outcomes?of racism on birth outcomes?
A MULTIETHNIC COMPARISONA MULTIETHNIC COMPARISON
Prospective, repeated measures surveyProspective, repeated measures survey
Psychosocial, medical, physiological variablesPsychosocial, medical, physiological variables
480 Ethnically/socioeconomically diverse 480 Ethnically/socioeconomically diverse
pregnant womenpregnant women
Recruited in clinics or referred by private Recruited in clinics or referred by private
MDsMDs
Fluent EnglishFluent English
>> 18 yrs, 18 yrs, < < 18 wks gestation, non-smokers18 wks gestation, non-smokers
MS-BIPS DESIGNMS-BIPS DESIGN
70 70 LatinasLatinas
177 177 Nonhispanic WhitesNonhispanic Whites
25 25 Asian/Pacific IslandersAsian/Pacific Islanders
5151 African-AmericansAfrican-Americans
with racism datawith racism data
SAMPLE consisted ofSAMPLE consisted of
Variable AfrAm API Latina White p-value
Income 2.3(1.7) 3.6(1.8) 2.0(1.4) 4.0(1.6) 0.000
College 19.6% 60.0% 17.1% 66.1% 0.000
Work 45.1% 60.0% 70.0% 77.0% 0.000
Cohab 66.7% 100.0% 88.6% 94.8% 0.000
US born 100.0% 48.0% 75.7% 93.1% 0.000
SOCIODEMOGRAPHICSSOCIODEMOGRAPHICS
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
Are there ethnic differences Are there ethnic differences
in perceived lifetime exposure in perceived lifetime exposure
to racism?to racism?
Have you ever felt that you (or someone Have you ever felt that you (or someone
close) were discriminated against or the close) were discriminated against or the
target of prejudice b/c of race in target of prejudice b/c of race in
interpersonal, housing, employment, interpersonal, housing, employment,
educational, other situations?educational, other situations?
INTERPERSONAL RACISMINTERPERSONAL RACISM
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
Variable AfrAm API Latina White p-value
PERS_C 1.5(1.7) 1.6(1.6) 0.7(0.9) 0.5(0.9) 0.000
PERS_D 58.7% 72.0% 44.3% 27.4% 0.000
RACISM EXPERIENCESRACISM EXPERIENCES
PERSONALPERSONAL
Unadj: APIs & AFrAms / Latinas & Whites
Adj: Latinas / Whites
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
Variable AfrAm API Latina White p-value
VIC_C 1.9(2.0) 1.5(2.0) 0.8(1.3) 0.5(1.1) 0.000
VIC_D 63.0% 60.0% 37.1% 29.9% 0.000
RACISM EXPERIENCESRACISM EXPERIENCES
VICARIOUSVICARIOUS
Unadj: APIs & AFrAms / Latinas & Whites
Adj: Latinas / Whites
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
Variable AfrAm API Latina White p-value
Child_C 1.5(1.8) 1.8(1.9) 0.9(1.4) 0.5(1.0) 0.000
Child_D 51.1% 80.0% 40.0% 25.6% 0.000
RACISM EXPERIENCESRACISM EXPERIENCES
AS A CHILDAS A CHILD
Unadj: APIs & AfrAms / Latinas & Whites
Adj: AfrAms do not differ from Latinas
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
Variable AfrAm API Latina White p-value
Adult_C 2.0(2.2) 1.3(1.8) 0.6(0.9) 0.5(1.0) 0.000
Adult_D 63.0% 60.0% 37.1% 29.9% 0.000
RACISM EXPERIENCESRACISM EXPERIENCES
AS AN ADULTAS AN ADULT
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
Are there ethnic differences Are there ethnic differences
in the impact of racism on in the impact of racism on
psychosocial functioning psychosocial functioning
in pregnancy?in pregnancy?
Stressful Life EventsStressful Life Events
Perceived Stress (PSS)Perceived Stress (PSS)
State Anxiety (STAI)State Anxiety (STAI)
Pregnancy-related AnxietyPregnancy-related Anxiety
Depression (CES-D)Depression (CES-D)
Personal ResourcesPersonal Resources
PSYCHOSOCIAL FUNCTIONINGPSYCHOSOCIAL FUNCTIONING
ETHNIC DIFFERENCESETHNIC DIFFERENCES
UnadjustedUnadjusted
AfrAms & Latinas higher AfrAms & Latinas higher PSSPSS than Whites than Whites
AfrAms higher AfrAms higher CES-DCES-D than Whites than Whites
Latinas marginally higher Latinas marginally higher Preg AnxPreg Anx than than WhitesWhites
AdjustedAdjusted
Whites lower Whites lower Preg AnxPreg Anx than Latinas and APIs than Latinas and APIs
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
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
No evidence that racism’s o evidence that racism’s
impact on psychosocial impact on psychosocial
functioning was moderated functioning was moderated
by race.by race.
INTERACTIONSINTERACTIONS
Are there ethnic differences Are there ethnic differences
in the impact of racism on in the impact of racism on
birth outcomes?birth outcomes?
White 3484.40 (554.63)
Latina 3447.33 (600.21)
API 3226.88 (715.70)
AfrAm 3216.86 (508.72)
BIRTHWEIGHT DIFFERENCESBIRTHWEIGHT DIFFERENCES
Unadj: Whites / AfrAms
Adj: Whites / AfrAms & APIs
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
White 39.15 (1.60)
Latina 38.76 (2.00)
API 38.14 (2.77)
AfrAm 38.60 (1.96)
Gestational Age DifferencesGestational Age Differences
Unadj: Whites / APIs (marginal)
Adj: NS
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** -0.13-0.13**
GAGA -0.12-0.12** -0.12-0.12**
*p<0.05*p<0.05
Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004Parker Dominguez, Dunkel Schetter, Glynn, Hobel, & Sandman, 2004
No evidence that racism’s o evidence that racism’s
impact on birth outcomes impact on birth outcomes
was moderated by race.was moderated by race.
INTERACTIONSINTERACTIONS
Ethnic differences in racism exposure, distress, Ethnic differences in racism exposure, distress,
and copingand coping
Racism impacts psychosocial fx and birth Racism impacts psychosocial fx and birth
outcomesoutcomes
Physiological mediators important to elucidatePhysiological mediators important to elucidate
ConclusionsConclusions
Christine Dunkel SchetterChristine Dunkel Schetter
Department of Psychology, UCLADepartment of Psychology, UCLA
Curt SandmanCurt Sandman
Department of Psychiatry, UC-IrvineDepartment of Psychiatry, UC-Irvine
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
AcknowledgementsAcknowledgements