key: cord-0889871-guhvwh1y
authors: Bogulski, Cari A.; Willis, Don E.; Williams, Christina A.; Ayers, Britni L.; Andersen, Jennifer A.; McElfish, Pearl A.
title: Stressful life events and social support among pregnant Marshallese women
date: 2022-05-12
journal: Matern Child Health J
DOI: 10.1007/s10995-022-03404-7
sha: ac8f635b116bc778c6a4eff97728b5b044c7b575
doc_id: 889871
cord_uid: guhvwh1y

INTRODUCTION: Women from racial and ethnic minority groups in the United States are disproportionately likely to experience adverse perinatal outcomes such as preterm birth, low birthweight infants, and infant mortality. Previous research has demonstrated that exposure to stressful life events and social support may influence perinatal outcomes. Although studies have documented stressful life events and social support for the general United States population and minority groups, less is known about the experiences of Pacific Islander women in the United States, and no prior studies have documented these experiences in Marshallese Pacific Islander women. METHODS: The present study examined data collected from pregnant Marshallese women (n = 67) in northwest Arkansas participating in a women’s health program using descriptive analyses (means, standard deviations, proportions). RESULTS: Results indicated a high prevalence of three stressful life events: experiencing a family member going into the hospital (35.8%), someone close to them dying (29.9%), and being unable to pay bills (53.7%). Food insecurity was higher than previously reported for pregnant women or Pacific Islanders (83.7%). Social support was high among the sample. A majority of women reported receiving help with daily chores (86.6%), help when sick (88.1%), and support on how to deal with personal problems (85.1%). DISCUSSION: This study is the first to document the prevalence of stressful life events and social support in a sample of pregnant Marshallese women living in the United States. The findings provide important information to guide efforts to reduce adverse perinatal outcomes in a Pacific Islander population.

; Working Group of the Applied Research Center & the National Council of Asian Pacific Americans 2013). Data available include limited studies demonstrating that Pacific Islander women experience higher prevalence of preterm birth and lower birthweight infants and are also more likely to experience preeclampsia, primary cesarean delivery, excessive gestational weight gain, and gestational diabetes mellitus (Chang et al., 2015; Chang et al., 2010; Choi, 2008; Hawley et al., 2014; Utah Department of Health, 2009; Nembhard et al., 2019; Schempf et al., 2010; Shen et al., 2005; Todd & Peabody, 2004) .

The majority of Pacific Islanders in Arkansas are Marshallese migrants from the Republic of the Marshall Islands, where the US tested nuclear weapons between 1946 and 1958 (Arkansas Department of Education Data Center, 2016; Arkansas Department of Health & Arkansas Vital Records Office, 2015; Barker, 2012; McElfish et al., 2015; United States Census Bureau, 2010a , 2010b ). Tests exposed islanders to significant levels of nuclear radiation (Barker, 2012; Guyer, 2001; Pollock, 2002) . Studies have demonstrated health problems affecting exposed individuals and changes in Marshallese health behaviors (Barker, 2012; Gittelsohn et al., 2003; McElfish et al., 2016; McLennan & Ulijaszek, 2015) . Previous analyses of birth records (n = 2,488) documented the following among Marshallese living in Arkansas: 15% of Marshallese women received no prenatal care (compared to 1.6% women nationally); half do not receive prenatal care visits during their first trimester (compared to 22.9% nationally); 19% of Marshallese infants were born preterm (compared to 9.6% nationally); and 15% of Marshallese infants were low birthweight (compared to 8.3% nationally; Nembhard et al., 2019; Osterman & Martin, 2018) . Despite evidence of adverse perinatal outcomes for Marshallese women, no research explores stressful life events among Marshallese or other Pacific Islander pregnant women. The present study fills this gap in the literature by examining the prevalence of stressful life events and social support among pregnant Marshallese women.

Methods. Data Sources and Participants. Data were collected from the enrollment survey for a women's health program offered by the University of Arkansas for Medical Sciences. Both pregnant and non-pregnant women take part in the program; however, only pregnant women are included in the study. Participants provided verbal consent for data collection at the time of enrollment. The data collection portion of the women's health program was conducted in accord with prevailing ethical principles and was determined by the University of Arkansas for Medical Sciences Institutional Review Board to be exempt (#239466). Sixty-seven pregnant Marshallese women adds to this literature and is the first to report prevalence of stressful life events and social support in a Marshallese Pacific Islander population in the United States.

Introduction.

In the United States (US), public health efforts have contributed to the reduction in adverse perinatal outcomes (Centers for Disease Control and Prevention 2021a, 2021b). Despite these efforts, racial and ethnic minority inequities in perinatal outcomes persist (Centers for Disease Control and Prevention 2021b, 2021a; Willis et al., 2014) . Social determinants of health have been identified as contributing factors (Amjad et al., 2019; Giurgescu, 2017; Healthypeople. gov, 2019; Thoma et al., 2019) , and research demonstrates stressful life events may be a contributing factor to adverse perinatal outcomes (Harville et al., 2010; Hux & Roberts, 2015; Mendez-Figueroa et al., 2019; Oyarzo et al., 2012; Traylor et al., 2020) . Stress exposure across the life course activates physiological responses and accelerates biological aging, undermining health generally (Danese & McEwen, 2012) . Acute and chronic stress have been associated with a variety of adverse perinatal outcomes such as preterm birth, preeclampsia, infant morbidity, and low birthweight infants (Vianna et al., 2011; Wadhwa et al., 2011) . In 2010, data from the Centers for Disease Control Pregnancy Risk Assessment Monitoring System (PRAMS) found 75% of women reported at least one stressful event during their pregnancy (Burns et al., 2015) . The most common stressors included moving, serious illness of a family member, and inability to pay bills (Burns et al., 2015) . Racial and ethnic minority women are often at risk for multiple stressful life events during pregnancy (Lu & Chen, 2004; Silveira et al., 2013; Zhao et al., 2015) . The risk of exposure to stress during pregnancy is higher for low-income women of color (Hatch & Dohrenwend, 2007; Koning & Ehrenthala, 2019) , including financial struggles, job loss or unemployment, food insecurity, domestic violence, and homelessness (Borders et al., 2007; Braveman et al., 2010) .

Research has documented the disparities in stressful life events for pregnant Black and Hispanic women (Brunst et al., 2014; Dominguez, 2008; Grobman et al., 2018; Lefmann et al., 2017) , but less is known about stressful life events and social support for Pacific Islander women (Schempf et al., 2010) . Pacific Islanders are the second-fastest growing population in the US (Hixson et al., 2012) . Arkansas has had especially high growth, with the Pacific Islander population increasing 252% between 2000 and 2010 (Arkansas Department of Education Data Center, 2016; Arkansas Department of Health & Arkansas Vital Records Office, 2015) . Pacific Islanders are underrepresented in research, and available research often aggregates data across Pacific Islanders and Asian Americans, obscuring disparities (Park et al., 2009; Ro & Yee, 2010; Roehr, 2010 ; Schempf et rent, and 80% reported concern with non-payment of utilities or utility shut-off ( Table 2) .

More than three-fourths of participants reported one or more stressful life events (76.2%), and over half reported at least two stressful life events in the past twelve months (55.3%). A majority of participants reported having experienced problems paying the rent, mortgage, or other bills (53.7%), and 21% of participants reported moving to a new address. Over one-third of participants reported having a close family member who was very sick and had to go into the hospital (35.8%), and 30% reported having someone very close to them die. For social support, a majority of participants reported having someone available to help completed the program's enrollment survey between July 2019 and January 2021.

Measures and Data Collection. Care coordinators administered questions to participating clients and recorded responses in REDCap (Research Electronic Data Capture; Harris et al., 2009; Harris et al., 2019) . Stressful life events were measured using the Modified Life Events Inventory 14-item scale (Newton et al., 1979) as utilized in PRAMS (Shulman et al., 2018) , and social support was measured using an abbreviated Medical Outcomes Study social support survey (Sherbourne & Stewart, 1991) , with those reporting "all of the time" or "most of the time" as having social support. A validated 2-item food insecurity assessment was also added in December 2019 as part of quality improvement; therefore, these items were not administered to all participants (Hager et al., 2010) . Additional measures collected and analyzed (e.g., health insurance status; father/partner involvement; Special Supplemental Nutrition Program for Women, Infants, and Children [WIC] and Supplemental Nutrition Assistance Program [SNAP] needs assessment; and housing insecurity) were assessed using questions adapted from PRAMS (Shulman et al., 2018) .

Data Analysis. Descriptive statistics, including means and standard deviations for continuous variables and proportions for categorical variables, are presented to characterize participants. Analyses included participant demographics and the domains of interest: stressful life events, social support, health insurance status, father/partner involvement, WIC/ SNAP needs assessments, housing insecurity, and food insecurity. All analyses were conducted using R/RStudio (R Core Team, 2019; RStudio Team, 2018).

Results.

Participants had a mean age of 28.2 (SD = 6.6) at enrollment in the program, and 42.2% of participants reported being uninsured. A majority of participants were married, a member of an unmarried couple, or living with a partner (77.3%) and had a high school degree/GED or less (83.6%). Participants reported an average household size (adults and children) of 6.1 (SD = 2.8). A majority of participants reported needing, but not having applied for, WIC (71.6%) and SNAP (59.7%). Several participants reported already receiving or having applied for WIC (17.9%) and SNAP (17.9%) ( Table 1) .

A majority of participants were food insecure (83.7%). None of the participants reported home ownership, and almost all reported renting or sharing a home (97%). Over one-third (37.3%) of pregnant Marshallese women reported having a concern about housing; of those, 84% reported unstable housing due to non-payment of rent or past due The health insurance question allowed for multiple response options. Responses have been collapsed and re-coded.

Factor Surveillance System data showed 33.6% of pregnant Pacific Islanders in Hawaii were food insecure (Stupplebeen, 2019). Moreover, only 16.4% and 13.4% of participants reported currently receiving WIC and SNAP benefits, respectively. Our results indicate 71.6% of participants needed to apply for WIC benefits, and 59.7% needed to apply for SNAP benefits but had not done so. These findings demonstrate pregnant women may need more assistance in the application process for benefits, helping to alleviate food insecurity during pregnancy.

Housing was also a concern for many participants (37.3%), and more than half (53.7%) of participants reported worrying about paying the rent, mortgage, or other bills. Previous studies have found 44.8-46% of adults living in Hawaii worried about paying rent and other bills (Pobutsky et al., 2015; Stupplebeen, 2019) , so a higher proportion in Arkansas is surprising, given Hawaii has the highest cost of with daily chores (86.6%), help if they were sick (88.1%), or turn to for suggestions about how to deal with a personal problem (85.1%). Almost all participants (92.5%) reported having a supportive partner (Table 3) .

Discussion. This study examined the prevalence of stressful life events and social support among pregnant Marshallese women living in Arkansas. Pregnant Marshallese women face many stressful life events stemming from socioeconomic and health inequities while also reporting strong social support within and among families. Participants reported a high prevalence of family members being hospitalized (35.8%), someone close to them dying (29.9%), and being unable to pay bills (53.7%). The proportions for these three specific stressful life events were higher in this study than in any racial/ethnic subpopulations reported in a larger PRAMS study (Lu & Chen, 2004 ; see Limitations for possible effects of the COVID-19 pandemic).

Until recently, unequal death exposure has been an overlooked source of racial/ethnic health disparities in the US . The exposure to death through the loss of a loved one is one of the most stressful life events people experience, leading to a potential loss of resources, including social support. The loss of resources alters one's social environment in ways that may lead to additional stressful events (Pearlin et al., 2005; Umberson, 2017) . The accumulation of stressful events across the life course have been shown to activate physiological responses that may lead to adverse perinatal outcomes (Danese & McEwen, 2012; Hux et al., 2014; Vianna et al., 2011; Wadhwa et al., 2011) .

Many of the pregnant Marshallese women reported social support in the form of receiving help with daily chores (86.6%), receiving help when sick (88.1%), and having someone to turn to for suggestions about how to deal with personal problems (85.1%). Although social support has been documented as generally protective against negative health outcomes and as important resources for coping with stress (Umberson & Karas Montez, 2010) , reviews of this literature reveal the somewhat limited benefits of social support (Thoits, 1995) . Marshallese women in this study reported high levels of both stressful life events and high levels of social support, raising questions about the capacity of social support to cope with stressful events in a population that faces multiplicative stressors.

The prevalence of food insecurity among participants was extremely high (83.7%). This reported level of food insecurity is much higher than has been documented during pregnancy in other populations including Pacific Islanders living the US. Prior to the COVID-19 pandemic, 10.5% of the US population was estimated to be food insecure (Coleman-Jensen et al., 2020) , and a study of Behavioral Risk (0) Non-payment of utilities or utility shut-off 20 (80) Housekeeping concerns (failure to maintain cleanliness of the unit)

Housing is or will be condemned 0 (0) Friend or family member being evicted or threatened with eviction 0 (0) Threat of abuse by partner, family member, or other 0 (0) Being discharged or service is being terminated 0 (0) Personal conflict with others 0 (0) Other health or safety concerns 0 (0) Other lease violation(s) 0 (0) Other 1 (4)

can inform public health interventions for the Marshallese living in the US (1st ) and Arkansas has the second-lowest (50th ) (US Department of Commerce, Bureau of Economic Analysis, 2020). Lack of reported health insurance was also notably high (42.2%) in the sample relative to other groups of Pacific Islanders living in the US (Park et al., 2018) . However, the lack of insurance is similar to the previously-reported proportion of uninsured Marshallese adults in Arkansas (46.4%) . Prior to early 2021, Marshallese adults living in the US were not eligible to receive Medicaid benefits unless they were pregnant due to their Compact of Free Association (COFA) migrant status (McElfish et al., 2015) . Of particular concern is that almost half of pregnant Marshallese women in Arkansas report they are uninsured despite being eligible for Medicaid. The results indicate a need for additional efforts to assist with Medicaid applications, both for currently pregnant women and for the Marshallese community as a whole as they become eligible for Medicaid benefits.

Limitations.

Results should be interpreted with limitations in mind. The study sample size was small, and all women in the sample are part of a women's health program; therefore, the results of this study may not be generalizable to other Pacific Islanders or to Marshallese residing outside of Arkansas. Although data were collected from pregnant participants, participants varied in their gestational age during data collection, which may introduce variability in experiences of social support and stressful life events. Additionally, though measured using an abbreviated Medical Outcomes Study social support survey (Sherbourne & Stewart, 1991) , social support was adapted and abbreviated by a nationally-convened Collaborative Improvement and Innovation Network specific to the women's health program and, thus, cannot be scored and compared to previous studies utilizing the original scale. Of additional importance is acknowledging the potential effects of COVID-19 in this study, as approximately one-third of participants were enrolled during or after March 2020 (n = 22). The COVID-19 pandemic may have had an effect on both the number of stressful life events and amount of social support received during this time period. The Marshallese have experienced disproportionately high rates of COVID-19 infection, hospitalization, and death from COVID-19 (Center et al., 2020) . Despite these limitations, this study is the first to document stressful life events and social support among Marshallese pregnant women residing in the US.

Policy Implications.

Using research findings to assist communities is an important part of the community-engaged participatory approach (Chen et al., 2010; Purvis et al., 2017) . In addition to contributing new knowledge, insights from this study My husband/partner or parent/guardian lost his or her job 8 (11.9) I lost my job even though I wanted to go on working 1 (1.5) My husband/partner, parent/guardian, or I had a cut in work hours or pay 5 (7.5) I was apart from my husband/partner or parent/guardian due to military deployment or extended work-related travel 

Code availability All analyses were conducted using R/RStudio.

The authors declare that they have no conflict of interest.

The data collection portion of the women's health program was conducted in accord with prevailing ethical principles and was determined by the University of Arkansas for Medical Sciences Institutional Review Board to be exempt (#239466).

Participants provided verbal consent for data collection at the time of enrollment.

community. We find that Marshallese women experience several specific stressful life events immediately prior to or during pregnancy, including high prevalence of family health stress, financial and housing instability, food insecurity, lack of health insurance, and lack of WIC and SNAP support. The University of Arkansas for Medical Sciences women's health program addresses numerous concerns identified in this study and provides Marshallese care coordinators to help pregnant Marshallese women: (1) enroll in health insurance; (2) utilize health insurance; and (3) connect with resources such as WIC, SNAP, and food pantries. This study also revealed high levels of family support in the Marshallese community. Previous studies have indicated health behavior interventions incorporating a family model is highly effective among Pacific Islander communities (McElfish et al., 2021; McElfish et al., 2019) . Future interventions should incorporate group or family-centric models for pregnant Pacific Islander women.

Conclusion. This study is the first to document stressful life events and social support among pregnant Marshallese women. The findings show evidence of the considerable economic, social, and health challenges these women face. The findings also show strong evidence of the ability of the highly collectivistic and family-oriented Marshallese culture to provide strong social support within their community (Yeary et al., 2017) . The high levels of both stressful life events and social support indicate need for further study to better understand the capacity of social support to protect against stressful life events during pregnancy.

Acknowledgments None.

Authors' contributions CAB performed all analyses, finalized edits for the entire article, and worked with CAW and DEW to create initial framing of the article based on analyses; DEW provided edits throughout and worked with CAB and CAW to help create initial framing of the article based on analyses; CAW provided edits throughout, provided feedback on framing and analyses, worked with CAB and DEW to help create initial framing of the article based on analyses, and performed the first draft of the literature review on social support and stress; BLA provided edits throughout, performed the first draft of the literature review on women's health and Marshallese/Pacific Islander background, and provided the first draft of policy implications; JAA provided edits and feedback on framing and analyses; PAM provided edits throughout and guiding framing of the article at every step. 

Social determinants of health and adverse maternal and birth outcomes in adolescent pregnancies: A systematic review and meta-analysis. Paediatric and Perinatal Epidemiology

Bravo for the Marshallese: Regaining Control in a Post-Nuclear, Post-Colonial World. Cengage Learning Borders

Poverty, near-poverty, and hardship around the time of pregnancy

Effects of prenatal social stress and maternal dietary fatty acid ratio on infant temperament: Does race matter?

Stressful life events experienced by women in the year before their infants' births-United States

metadata-driven methodology and workflow process for providing translational research informatics support

The REDCap consortium: Building an international community of software platform partners

Childhood hardship, maternal smoking, and birth outcomes: a prospective cohort study

Distribution of traumatic and other stressful life events by race/ethnicity, gender, SES and age: A review of the research

Barriers to adequate prenatal care utilization in American Samoa

Maternal, Infant, and Child Health

Allostatic load in women with a history of low birth weight infants: The National Health and Nutrition Examination Survey

A potential role for allostatic load in preeclampsia

Stressor landscapes, birth weight, and prematurity at the intersection of race and income: Elucidating birth contexts through patterned life events. SSM -Population Health

Examining the inter-correlated effects of low income, life stress, and race on birth outcomes: A representative state study. Social Work in Health Care

Racial and ethnic disparities in preterm birth: the role of stressful life events

Family Model Diabetes Self-Management and Support in Faith-Based Organizations in the Republic of the Marshall Islands Study Protocol

Health beliefs of Marshallese regarding type 2 diabetes

Effect of US health policies on health care access for Marshallese migrants

Multidisciplinary Community-Based Investigation of a COVID-19 Outbreak Among Marshallese and Hispanic/Latino Communities -Benton and Washington Counties

Maternal risk factors and perinatal outcomes among pacific islander groups in Hawaii: a retrospective cohort study using statewide hospital data

The prevalence of gestational diabetes among Micronesians in Honolulu

Dissemination of results in community-based participatory research

Seeking health care: Marshallese migrants in Hawai'i

Household Food Security in the United States in 2019 (ERR-275). United States Department of Agriculture

Adverse childhood experiences, allostasis, allostatic load, and age-related disease

Race, racism, and racial disparities in adverse birth outcomes

Macro-and microlevel processes affect food choice and nutritional status in the Republic of the Marshall Islands

Social determinants of maternal health and birth outcomes

& Eunice Kennedy Shriver National Institute of Child Health and Human Development Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b) Network. Racial disparities in adverse pregnancy outcomes and psychosocial stress

Radioactivity and rights: Clashes at Bikini Atoll

Development and validity of a 2-item screen to identify families at risk for food insecurity

Out of the shadows: Asian Americans, Native Hawaiians, and Pacific Islanders

Asians and Pacific Islanders in US need greater prominence in research

Perinatal outcomes for Asian, Native Hawaiian, and other Pacific Islander Mothers of single and multiple race/ethnicity: California and Hawaii

Disparities in maternal outcomes among four ethnic populations

The MOS social support survey

The pregnancy risk assessment monitoring system (PRAMS): Overview of design and methodology

Correlates of high perceived stress among pregnant Hispanic women in Western Massachusetts

Toward improved health: disaggregating Asian American and Native Hawaiian Pacific Islander data

Housing and Food Insecurity and Chronic Disease Among Three Racial Groups in Hawai'i

Stress, coping, and social support processes: Where are we? What next?

Black-white disparities in preterm birth: Geographic, social, and health determinants

Maternal predictors of infant health outcomes among Hawaiians

Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review

Black deaths matter: Race, relationship loss, and effects on survivors

Social relationships and health: A flashpoint for health policy

Death of family members as an overlooked source of racial disadvantage in the United States

Diabetes and hypertension in Marshallese adults: Results from faith-based health screenings

Conquering racial disparities in perinatal outcomes

Best Practices: Researching Asian Americans, Native Hawaiians and Pacific Islanders

Cultural adaptation of diabetes selfmanagement education for Marshallese residing in the United States: Lessons learned in curriculum development

Association between life event stressors and low birth weight in African American and White populations: Findings from the

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Profile of general population and housing characteristics

Distress conditions during pregnancy may lead to pre-eclampsia by increasing cortisol levels and altering lymphocyte sensitivity to glucocorticoids

The contribution of maternal stress to preterm birth: issues and