Mechanisms linking child health care use and maternal depression

描述(申请人提供)：产妇抑郁在低收入少数族裔妇女中很普遍，并与更多地使用以问题为导向的儿童保健服务有关，包括病童就诊、急诊科就诊和住院。人们提出了多种机制来解释这些关联，但很少有经验性测试。这项研究的总体目标是通过研究潜在的中介机制来提高对母亲抑郁如何影响儿童保健使用的理解。对这些机制与儿童保健使用之间的关联的调查将为制定更有针对性的干预措施的战略提供见解。第一个具体目标是确定两种机制(自我效能和母婴互动)是否是抑郁症状和以问题为导向的儿童保健使用之间的中介。自我效能感是一种信念，即一个人可以有效地完成某项任务。母子互动描述了母亲和孩子通过发送、接收和对暗示做出反应而相互沟通的情况。第二个具体目标是探讨产妇抑郁对儿童保健使用模式的影响，重点放在三个不同的方面：非卧床护理敏感情况(预计会随着抑郁症状增加)、作为初级保健替代的急诊科就诊以及健康儿童就诊(预计随着抑郁症状减少)。关于门诊护理敏感情况的现有证据没有得到复制，健康儿童就诊的证据也不一致。急诊科就诊尚未被测试为替代初级保健。测试上述关系的计划方法是线性回归和负二项回归，但使用健康儿童访问将使用有序Logit回归。抑郁症和自我效能感与卫生保健使用的关系将被允许是非线性的，可能是二次关系。模型规格试验将确认计划的方法和功能形式是否合适。急诊科就诊和住院将被归类为门诊护理敏感或不使用医疗记录中的诊断。所有分析都将根据儿童的慢性病和出生体重进行风险调整。共同的人口统计变量将被用来控制可能有助于卫生保健使用的其他因素。来自田纳西州孟菲斯的护士-家庭伙伴关系试验的对照对象的数据将被使用(n=460)。母亲们在怀孕期间以及孩子36周、6个月、12个月和24个月大的时候接受了采访。这些孩子的医疗记录被获取了长达24个月。如果自我效能感和/或母子互动被发现是儿童保健使用的重要因素，除了抑郁之外，需要采取适当的干预措施来解决这些情况，才能对使用产生重大影响。幸运的是，干预措施在提高自我效能感和母子互动方面取得了成功。成功的干预将侧重于减少额外的酌情访问的需要，而不会阻碍适当的访问。第二个具体目标发现的模式可能会为政策决策和未来的研究假设提供参考。 公共卫生相关性：这项研究试图了解母亲抑郁如何增加抑郁症母亲的孩子就诊、急诊科就诊和住院治疗的数量。了解解释这些关联的具体机制将有助于设计更成功的干预措施，从而更有效地利用卫生保健资源以及更健康的家庭。

DESCRIPTION (provided by applicant): Maternal depression is prevalent among low-income minority women and is associated with increased use of problem-oriented child health care services including sick-child visits, emergency department (ED) visits, and hospitalizations. A variety of mechanisms to explain these associations have been suggested, but few have been empirically tested. The overall goal of this research is to improve the understanding of how maternal depression impacts child health care use by examining potential mediating mechanisms. The investigation of the association between these mechanisms and child health care use will provide insights into strategies for developing more targeted interventions. The first specific aim is to determine if two mechanisms (self-efficacy and maternal-child interactions) are mediators between depressive symptoms and problem-oriented child health care use. Self-efficacy is the belief that one can be effective at a certain task. Mother-child interactions describe how well the mother and child communicate with each other through sending, receiving, and reacting to cues. The second specific aim is to explore how patterns of child health care use are impacted by maternal depression, focusing on three separate aspects: ambulatory care sensitive conditions (expected to increase with depressive symptoms), ED visits as a substitute for primary care, and well-child visits (expected to decrease with depressive symptoms). The existing evidence for ambulatory care sensitive conditions has not been replicated and the evidence for well-child visits is inconsistent. ED visits have not been tested as a substitute for primary care. The planned methods for testing the above relationships are linear and negative binomial regression, except for utilization of well-child visits which will use ordered logit regression. The relationships of depression and self-efficacy with health care use will be allowed to be non-linear, possibly quadratic. Model specification tests will confirm if the planned methods and functional forms are appropriate. ED visits and hospitalizations will be classified as ambulatory care sensitive or not using diagnoses in the medical records. All analyses will be risk adjusted for children's chronic conditions and birth weight. Common demographic variables will be used to control for other factors that may contribute to health care use. Data from the control subjects of the Nurse-Family Partnership trial in Memphis, TN will be used (n=460). Mothers were interviewed during pregnancy and at the child's ages of 36 weeks, 6 months, 12 months, and 24 months. Medical records for the children were obtained up to 24 months. If self-efficacy and/or mother-child interactions are found to be important contributors to child health care use, appropriate interventions will need to address these conditions in addition to depression to substantially impact utilization. Fortunately, interventions have been successful at improving both self-efficacy and mother-child interactions. A successful intervention would focus on decreasing the need for additional discretionary visits, without discouraging appropriate visits. Patterns uncovered by the second specific aim may inform policy decisions and future research hypotheses. Public Health Relevance: This study seeks to understand how maternal depression increases the number of sick-child visits, emergency department visits, and hospitalizations for children of depressed mothers. Understanding the specific mechanisms that explain these associations will allow for more successful interventions to be designed, resulting in more efficient use of health care resources as well as healthier families.