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Ethnic-Specific Perceptions of Altered Control Among American Women: Implications for

Health Promotion Programs After Pregnancy

BOBBIE STERLING, EILEEN FOWLES, SUNGHUN KIM, LARA LATIMER, and LORRAINE O. WALKER

School of Nursing, University of Texas at Austin, Austin, Texas, USA

This study describes some ethnically diverse psychosocial and be- havioral contexts that influence low-income postpartum women’s ability to focus on their health. Content analysis was conducted on data from ethnically concordant focus groups of low-income American Anglo, African American, and Hispanic women 12 to 24 months postpartum. All women described altered sense of “per- ceived control” as the context contributing to their postpartum health status, but sources and management of this perception var- ied by ethnicity. Effective health promotion interventions may in- clude self-image building activities, stress management strategies and interventions that include family members but should address unique ethnic-specific contexts of low-income mothers.

Although family support of new mothers is widely practiced throughout the world, mothers continue to experience psychosocial and physical health needs after the first 4–6 weeks of recovery from childbirth (Cheng, Fowles, & Walker, 2006; Mercer, 1995). New mothers experience emotional and psy- chological stressors throughout the first year postpartum that alter their physi- cal and emotional well-being and functioning. As a result they may be unable to engage in health promoting activities, such as preparing well-balanced meals or engaging in physical activity, as they strive to meet the demands of

Received 31 March 2009; accepted 24 August 2010. We would like to acknowledge our focus group co-facilitators: Drs. Alexandra Garcia,

Sandra Jenkins, and Susan Wilkinson. This study was supported in part by grant R01 NR 04679.

Address correspondence to Dr. Eileen Fowles, PhD, RNC-OB, School of Nursing, Univer- sity of Texas at Austin, 1700 Red River Street, Austin, TX 78701-1499, USA. E-mail: efowles@ mail.nur.utexas.edu

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parenting (Walker & Wilging, 2000). Consequently, low-income new mothers in particular may experience elevated depressive symptoms (Petterson & Al- bers, 2001) and higher prevalence of postpartum weight retention (Olson, Strawderman, Hinton, & Pearson, 2003; Parker & Abrams, 1993; Shrewsbury, Robb, Power, & Wardle, 2009; Wolfe, Sobal, Olson, Frongillo, & Williamson, 1997).

In this study of low-income American women we sought to under- stand their ethnic-specific (African American, Hispanic, and Anglo/White) psychosocial and behavioral contexts during postpartum. Understanding these contexts may aid in tailoring health promotion programs to reduce postpartum depressive symptoms and retained weight and increase mater- nal well-being. We believe these findings will be of interest in the United States and in other countries where international migration has led to ethnic diversity, such as countries of Europe and Oceania and to a lesser extent in Africa, Asia, and Latin America (Castles, 2000).

BACKGROUND

Depression and obesity (usually defined as a body mass index > 30; BMI) are examples of health-related conditions to which women are more vulnerable. As noted by the World Health Organization (WHO, 2009a), “Unipolar de- pression, predicted to be the second leading cause of global disability burden by 2020, is twice as common in women.” Although reports of the prevalence of diagnosed postpartum depression vary by country, its prevalence is sub- stantial in one or more countries on virtually every continent (Halbreich & Karkun, 2006). Similarly, obesity is more prevalent in women than in men (WHO, 2000). Among 91 WHO member states reporting rates of obesity between 2000 and 2006 for female adults 15 or more years of age, more than half reported obesity rates of 10% or higher. These rates occurred in countries as diverse as Columbia, Canada, Egypt, Lithuania, Spain, Mongolia, and Zimbabwe (WHO, 2009b). Consequently, both postpartum depression (Halbreich & Karkun) and weight retention after pregnancy (Viswanathan et al., 2008) are important maternal health problems. Elevated depressive symptoms and depressed mood not only affect women’s quality of life (Da Costa, Dritsa, Rippen, Lownesteyn, & Khalife, 2006), but also that of their young children (Beck, 1998; Civic & Holt, 2000; Petterson & Albers, 2001). Similarly, postpartum retained weight may increase lifetime weight gain (Linne, Dye, Barkeling, & Rossner, 2004; Rooney, Schauberger, & Mathiason, 2005), which is worrisome for the health effects on women (Field et al., 2001; Must et al., 1999) and impact on future pregnancies (Cedergren, 2004; Cedergren, & Kallen, 2003). Postpartum interventions focused on physical activity, sound eating patterns, and improved coping (which reduce risk factors) in turn may reduce depressed mood and weight retention and pro- mote health among low-income women (Howell, Mora, DiBonaventura, &

Ethnic Context Affecting Weight Loss 41

Leventhal, 2009; Oken, Taveras, Popoola, Rich-Edwards, & Gillman, 2007; Olson et al., 2003).

Furthermore, customizing health promotion interventions is one tool to increase their suitability, appeal, effectiveness, and relevance to low-income women. Focus group interviews (Krueger & Casey, 2000) or other interview methods are commonly used to gather data that may guide the develop- ment of health promotion interventions for specific population subgroups. These approaches are particularly relevant when seeking information on commonalities and differences in individual experiences. Several authors have reported focus group or interview findings relevant to postpartum pro- grams for low-income or ethnic minority women (Amankwaa, 2003; Chang, Nitzke, Guilford, Adair, & Hazard, 2008; Ebbeling, Pearson, Sorensen, Levine, Hebert, et al., 2007; Kieffer, Willis, Arellano, & Guzman, 2002; Sterling et al., 2009; Thornton et al., 2006). One key finding for a sample of African Amer- ican and White women was that stress and negative emotions led to eating calorie dense foods and erratic meal eating patterns, but it was unclear if this affected one ethnic group more characteristically than another (Chang et al., 2008). In another study of Spanish-speaking Latinas, authors cited spousal preferences and support as important influences on timing of meals and composition of meals for women during pregnancy and the postpartum period (Thornton et al., 2006), but it remains unclear if these findings may apply to women of other ethnic groups.

In this study we extend an analysis of recently reported focus group data related to women’s perceptions of control in their lives after childbirth (Sterling et al., 2009). In that earlier report, a low-income, ethnically diverse sample of women recounted their experiences described within the overar- ching theme of altered perceived control related to weight and depressive symptoms after childbirth. Subsequent analyses revealed the presence of ethnically distinct themes that may be relevant to the development of post- partum health promotion programs. As a result, the purpose of this study is to report the ethnic-specific themes of Anglo (White), African American, and Hispanic women related to their psychosocial and behavioral contexts de- scribed within interviews more than 1 year postpartum. The ultimate goal was to incorporate knowledge of these ethnic-specific contexts into the design of an intervention program to reduce postpartum depressive symptoms and retained weight and to promote health among low-income American women.

METHODS

Focus Group Participants

A purposeful sample of 25 low-income women (6 Anglo, 9 African Amer- ican, and 10 Hispanic) participated in six ethnically concordant focus groups conducted in a university setting in the southwestern United States. These women had completed a year-long longitudinal study of pregnancy

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associated weight change and psychosocial and behavioral correlates of weight status among low-income ethnic minority women during postpartum (Walker, Freeland-Graves, et al., 2004). Women were invited if, at 12 months postpartum, they had a BMI of equal to or greater than 25 (WHO, 2000), had a total score of 16 or greater on the Center for Epidemiologic Study-Depression (CES-D; Radloff, 1977), or both (n = 10, 3, and 12, respectively). The preced- ing criteria were used to increase the likelihood that women would be able to describe experiences related to increased postpartum weight or depressive symptoms, or both. The high prevalence of each condition is likely to re- sult in a large number of low-income women with each condition (Walker, Timmerman, Kim, & Sterling, 2002; Walker, Timmerman, Sterling, Kim, & Dickson, 2004). Additional participant criteria included that women were 18 years or older; self-declared as Hispanic, African American, or Anglo (White) ethnicity; were able to speak and read English; had delivered no more than three children; were healthy, without coexisting medical problems during the pregnancy; had delivered a singleton healthy term newborn; and had low incomes defined as receiving prenatal care funded by Medicaid, a gov- ernment program with an income threshold of 185% of the federal poverty level. All focus group participants had received perinatal care by private physicians in a large metropolitan area in the southwest United States.

Demographic characteristics of women participating in this study are displayed by ethnic group in Table 1. The mean age of focus-group partici- pants at enrollment to the original longitudinal study was 24.3 years (SD ± 4.3). Eight women reported having a partial high school education, while 10 women had completed high school, and seven attended some college or had completed college. Eleven women reported a family income (at enroll- ment into the longitudinal study) of less than $15,000, while seven women reported a family income between $15,000 and $29,999. Thirteen women were living with a spouse or partner, while 11 were single at the time of initial enrollment into the larger study.

Study Protocol

University Institutional Review Board approval for this current study was received and participants signed informed consent forms. Each focus group consisted of 3–5 ethnically similar women and met for approximately 2 hours in a private room located in a women’s wellness center administered by a large university School of Nursing in the southwestern United States. Partic- ipants were informed that the purpose of the focus group was to receive women’s stories and experiences of stress (because of the stigma of mental health problems, we did not use the term “depression” or “depressive symp- toms” with participants) and weight changes during postpartum. All partic- ipants were familiar with the focus group cofacilitators and the geographic location because of their earlier participation in the longitudinal study. Two members of the research team served as focus group cofacilitators:

Ethnic Context Affecting Weight Loss 43

TABLE 1 Sample Demographics

Ethnicity

Variables Anglo African

American Hispanic Total

Number of participants (n) 6 9 10 25 Age (mean, year) 26.2 25.7 22.0 24.3 BMI at 12th month after delivery

(mean) 35.87 30.76 34.60 33.52

Depressive symptoms (CESD; mean)

18.50 21.18 26.13 22.52

Education (n) Partial high school 1 2 5 8 (32%) Completed high school 2 5 3 10 (40%) Some college 3 2 2 7 (28%)

Family income (n) <$15,000 1 3 7 11 (44%) $15,000–$29,999 2 3 2 7 (28%) >$30,000 2 3 0 5 (20%)

Married (n) Yes 2 4 7 13 (52%) No 4 4∗ 3 11 (44%)

Parity (n) 1 1 1 3 5 (20%) 2 4 4 3 11 (44%) 3 1 4 4 9 (36%)

Type of delivery (n) Vaginal 3 5 7 15 (60%) Cesarean 3 4 3 10 (40%)

Feeding method at delivery (n) Breastfeeding only 1 1 1 3 (12%) Combination 2 4 2 8 (32%) Formula only 3 4 7 14 (56%)

∗Data not available from one participant.

one was Anglo and the other was from the same ethnic background as the group members. Women received a small stipend at the completion of the study. Women in each ethnically concordant focus group were asked to respond to similar questions. Interview guide questions were developed through research team consensus and were designed to elicit the women’s experiences, perceptions, and interpretations of their ethnic-specific context of weight changes, stress, and depressive symptoms during postpartum. (See Figure 1 for examples of interview questions.)

Data Analysis

Participant responses to the focus group questions were analyzed us- ing established content analysis procedures (Miles & Huberman, 1994). Discussions were audio-taped and transcribed verbatim. One cofacilitator recorded field observations during focus group discussions that included descriptions of the setting and key points discussed. At the conclusion, the

44 B. Sterling et al.

• How has your weight changed since becoming pregnant and having your baby? • How have those weight changes affected you? • How do the weight changes in this recent pregnancy compare to the weight changes

in previous pregnancies? • What were some situations that caused you stress during your postpartum period? • Do you think that you are more or less healthy now than before pregnancy, and what

do you think led to your feeling of being more or less healthy?

FIGURE 1 Examples of focus group interview questions.

cofacilitator repeated these key points to the focus group participants for confirmation and further clarification. The other cofacilitator recorded obser- vations shortly after completion of the discussion. Cofacilitators compared their notes that also were used in the analysis. The analysis procedure in- volved two phases. In the first phase, selected members of the research staff (BS, SK, LL) analyzed transcripts independently. Participant statements were subjected to open coding so that recurring common themes and subthemes could be identified within the overarching theme of altered perceived con- trol. In the second phase, the major themes and subthemes unique to each ethnic group were identified and then compared by members of the staff (BS, SK, LL) for commonality and consistency. The concepts identified as ethnically specific then were compared again with those of the other groups and refined within the ethnic contexts. All members of the research team met on multiple occasions to identify the participant words and phrases that were the most representative textual examples describing the ethnic-specific context. This was done to ensure credibility of the findings and to identify and describe the ethnic-specific contexts accurately.

FINDINGS

Overarching Theme of Altered Perceived Control

The overarching theme of altered perceived personal control was descriptive of the lived context during postpartum in this sample of low-income ethni- cally diverse women (Sterling et al., 2009). For analysis purposes “perceived control” was defined as “the sense of managing some areas of their lives with their own knowledge and skills as well as preferences and choices.” Women in this sample described instances in which they lacked or had lost individual control of their lives and activities during the extended postpar- tum period, yet each ethnic group perceived this altered control differently and this perception had differing meanings for them. This overarching theme was manifested in statements about having no time to meet their own needs and struggling with heavy duties of child rearing. A subtheme of strategies to

Ethnic Context Affecting Weight Loss 45

manage or cope with the changes caused by the context also emerged. For instance, while all of the focus groups commented on the heavy responsibil- ities involved in childrearing, ethnically distinct coping strategies were used to manage the child-caring obligations and reflect an ethnic-specific context.

Anglo Mothers Context

For Anglo mothers, the context of “perceived control” was manifested in the theme of an altered sense of self. One characteristic of this theme was that Anglo mothers described how their postpartum health status, physical pain, and chronic fatigue differed from their prepregnancy state. Because of the postpartum weight retention, they felt “heavier” than they used to be and, in turn, were less physically active. Moreover, they recognized that their increase in TV watching and snacking contributed to the weight retention. The secondary analysis reported here reveals that this perception was unique to Anglo mothers:

[I feel] just heavier. . . . I don’t know, maybe a little bit lazier . . . not doing as much like watching more TV.

I don’t work, so I don’t do anything, so I’m sitting a lot, so I’m getting bigger and bigger . . . just mainly I didn’t realize how much sitting time I did and then since I sit at home, you know, I watch TV and I want to go get a snack, and I snack. I don’t really eat, I snack.

Many Anglo mothers complained about people’s preferences for body im- ages of “thinner” women and differences in expectations about physical size between women and men:

People tend to be nicer and kinder to “thinner” women.

Men and women both are obsessed with women’s size. Men’s size does not matter that much anywhere

Another characteristic of the Anglo mother’s theme of an altered sense of self revolved around changes in their self-image. One mother agonized about her conflicting feelings about being mother and a career woman, since she had been laid off during maternity leave from her prior workplace:

I went from a $40,000 a year job down to $8.50 an hour because my employer laid me off while I was on maternity leave. That was fun. And you sacrifice, you know. OK, am I going to go back to that and work 20 . . . be on call 24-7, possibly work six 8-hour days a week or am I going to be a Mom?”

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Anglo women adopted different approaches to manage the contextual changes by reframing their sense of self. Women who had conflicting feel- ings about being a mother and career woman managed by reframing their life priorities. One Anglo mother lamented, “I have no self-identity; I am just his Mom,” while another reframed her personal priorities by concluding the “Number one thing is being a Mom.” Another mother reframed her self- image by insisting that the dignity of a woman has nothing to do with her physical size but reflected the changes in sense of self during postpartum by saying, “I just want to become comfortable with myself and my size first.”

African American Mothers’ Context

For African American mothers, the context of altered “perceived control” was manifested in the theme focusing on the demands of parenting. One characteristic of this theme was that these mothers frequently mentioned the hardships of child care and their wishes to be relieved from the heavy duties:

I enjoyed and I believe that most of us do really enjoy being with our children and doing the motherly things, but . . . it did get overwhelming.

African American mothers appeared to live life “preoccupied” with chil- dren. Their schedule at work and home, the kinds of foods they ate, the methods of preparing meals, and physical activities were all framed with regards to the children:

There’s some days when I do a schedule, and I’ll stick to it, but then there’s some days when she [the baby] just doesn’t feel like it. She wants to do a whole other thing.

I think I try to wake up a little bit earlier before she wakes up in the morning, cause like I have time by myself. . . . I try to wake up a little bit early, she wakes up about 15–20 min-minutes later . . . but, you know, just have some quiet minutes for myself . . . just enough time to get me a quick shower and then . . . little feet are running around the couch.

My eating habit changed after I had the baby, cause it, I-I really felt like I had no time to just eat, you know, I skip breakfast, lunch. Sometime I eat at 4:00, sometime I eat at 1:00, and don’t eat again. I eat once a day, sometimes twice, but it’s the kids, it’s like whooo you just don’t have time to eat, cause it’s, I don’t know, it’s always something. So I know my eating habit is not good, but, it don’t. . . . I can’t change it because it’s, . . . I have no control.

Particularly, the responsibilities with multiple children were viewed as much more stressful than parenting a single child:

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Once you actually cook and get the kids there, and then one’s finished before the other, so you have to deal with that, and then it’s like, you know, you don’t actually find the time to sit down and eat, yourself, especially having the little one you have to feed . . . so it is kind of hard to get something for you.

I think it was just the stress of dealing with two children instead of one, you know, cause you got my son, but when you have a second kid [the baby], then you have to change the diaper, you got to make sure you have the bottles and the bibs and the this and the that, and then, I thought, it was just like adjusting to having another one.

African American mothers managed the contextual changes caused by de- mands of parenting in different ways. Some chose smoking, drinking, or both as one way of “escaping” from child-caring duties, being “relieved” from stressors, and having their own time. Although some mothers revealed mixed feelings because of the smoking-related diseases that other family members developed, many mothers agreed that smoking was a way of hav- ing their “quiet time” from their adverse circumstances:

Mine [smoking] started where I worked. Everybody else was taking a cigarette break, so, you know, I want to be like . . . (Laughter). I wanted my time to myself, and so now, I do it at home, but I don’t smoke in the house. I smoke outside, so that’s my time to myself, when I’m outside smoking a cigarette.

One of my friends smokes, she be like, “Go smoke a cigarette. It’d help.” I be like, “No.” But finally I did it and smoked a cigarette. And it relieved me from the kids, and I was like, “great feeling.”’

African American mothers also discussed an eagerness to have “adult con- versations” as another strategy to manage changes resulting from an altered sense of “perceived control” during postpartum. Specifically, participants who maintained their employment often considered the workplace as a good space for having adult conversations:

At least going to work and stuff you be able to, you know, laugh and talk.

That’s the main thing—talking to adults and not little kids. They can’t say anything.

Also, for some African American mothers, leaving the child to go to their job was a way of coping with child-rearing duties:

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[Mother talking about her husband] . . . uh, I was like, “How about you stay home, and I’ll go to work?” And he . . . he works from 3:00 to 11:00. I was working from 9:00 to 1:00 part time, and so that was my break, and that helped me get a schedule, get the kids on a schedule, and get myself on a schedule, and become more organized, and so, and I got my break even though I was working.

The demands of child care as a significant contextual event resulting in altered sense of perceived control was unique to African American women in this study.

Hispanic Mothers’ Context

For Hispanic mothers, the context of an altered sense of “perceived control” was manifested by the theme of family. These women made decisions or pursued health-related practices within the context of family. One character- istic noted was that family served as either a source of support or a source of stress. Even though help from close family members may not have eased the demands of child care, some Hispanic participants said their mother or partner was somehow helpful by “just being there”:

But my mother, she was always there, you know, emotionally, to give me my answers, and things like that.

Because my husband, right now, you know, he’s helping me a lot. I leave home at 5:00, so I can go in the library and do whatever I got to do, and finish up my homework or whatever, and he’s there.

In contrast, some Hispanic women did not always experience feelings of support from family members. Participants discussed difficulties in coping with their mother, spouse, or partner who at times imposed heavier burdens on daily life. One participant discussed the need to care for her sister’s children in addition to her own. Although she complained about the sister’s attitude about not carrying for her own children, the participant continued to assume primary care for both sets of children:

Because she [the sister of this participant] was in the process of . . . getting out of her house, and her boyfriend kicked her out, and so I had to take her to my house, and she had two kids, and I was taking care of them 24-7 . . .. It was real stressful for me . . . Because I was worried about her kids, because I had my two kids, and I had hers, so I was always just after them, you know, feeding them, bath . . . and putting them to bed. I was always doing stuff to them, so I didn’t have time for me.

Ethnic Context Affecting Weight Loss 49

Hispanic women employed several strategies to manage contextual changes in perceived control that resulted from both nuclear and extended family re- sponsibilities. To the Hispanic mothers, the increased focus on meeting their family’s needs seemed natural and even mandatory. This belief, however, resulted in a sacrificing or disregard of private or personal needs and often a sense of feeling guilty when engaging in activities focused on meeting their own needs if this took time away from meeting the needs of their children or family. One mother felt guilt when she took her children to a child care service so she could do something for herself, such as exercise.

I feel bad, like I’m taking, like I’m going to stick them in a day care and go do something for me. That makes me feel bad, you know . . . feel guilty.

In addition, several Hispanic mothers did not go to the 6-week postpartum checkup or did not see a doctor for their personal health conditions to fully take care of their children:

But, truthfully, since I’ve had the baby, you know, after you have the baby you see you have to go for the 6-weeks checkup. I still haven’t even been to the doctor for myself since I’ve had the baby. I haven’t even been to the doctor once. And while my husband tells me, he’s like, “You’re so caught up into her, you don’t even care about yourself anymore.”

I just don’t make the time for it. . . . I do take my son to the doctor when he needs to go, but I don’t for me. It’s, if I’m sick, I can handle it, but him he’s different.

Conversely, one mother managed the stress caused by family care demands in the context of altered perceived control by establishing a schedule for her life that included time needed for child care. Developing a schedule for herself and her children resulted in a certain level of perceived control in her life.

I think it’s important for us women to have a time for ourselves, . . . because, I mean, I know, in my home, I am, I have rules for my children. I get them to bed at 7:30, and from that time, I’m going to have my bath, do whatever I need to do that night for the next day.

I send her to my sister’s, you know, go play . . . with your little cousin, and they’ll go off and play, you know, while I can have some free time or (at) least and breathe or even if it’s just to relax and watch TV, just to myself. . . . You know, that’s my job [caring for child], but still I deserve time for myself. If not, you’ll go crazy.

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Summary of the Ethnic Specific Context

For Anglo participants, the context of altered control was the result of having lost the sense of self that they experienced before pregnancy. The prepreg- nancy perceptions of being thinner, having a better job, and having good relationships with friends and family members seemed to contribute to Anglo women perceiving an altered sense of self related to their weight, financial status, and relationships with significant others during the postpartum pe- riod. Contrary to their Anglo counterparts, African American women were not concerned about a lack of control over their past self-image. Rather, their context was related to a lack of control in response to child care demands. Managing contextual changes and stress by beginning or resuming smoking was a vivid indication that they did not have perceived control over their life. Different from their counterparts, Hispanic participants’ perception of control was situated within the context of the family. Hispanic mothers man- aged contextual changes during postpartum by attending to the needs of the family, which was unlike that of Anglo or African American mothers.

Summary of Managing Changes in Perceived Control

Anglo and Hispanic postpartum women seemed to manage changes in per- ceived control by reframing their perceptions. Anglo women reframed their life priorities, adapted to the altered body image, or sought positive rein- forcement for reporting healthy eating habits. Hispanic women reframed their priorities to coincide with their perceptions of the importance of meet- ing the needs of their family, which resulted in either a sense of control or, at times, guilt. When discussing the topics of smoking and drinking, we found that the purpose of smoking could be distinguishable for one ethnic group to the other. For African American mothers, smoking was an exit to their own time from the heavy requirements of child care and their life, whereas one Anglo American mother smoked as a strategy to manage or lose weight: “I’m smoking a lot more because I’m trying to lose weight.” Because the dis- cussion of smoking as a management strategy was not as prominent among Anglo American or Hispanic mothers as it was with their African American counterparts, however, the difference between these ethnic groups cannot be generalized.

DISCUSSION

Ethnic-Specific Themes

The transition to parenthood is a common experience that involves a dy- namic transformation when women’s perception of themselves solely as women change to include the perception of themselves as mothers in or- der to meet the needs of their infants (Mercer, 2004; Rubin, 1984). For the

Ethnic Context Affecting Weight Loss 51

low-income women in this study, who were selected because they were either overweight or at risk of elevated depressive symptoms (or both con- ditions), an overarching theme of altered perception of control was evident in their lives, a finding replicated from a prior analysis of this sample (Ster- ling et al., 2009). For Anglo, African American, and Hispanic women, the themes of altered sense of self, demands of parenting, and family, respec- tively, emerged as distinguishing features of their respective psychosocial and behavioral contexts during focus group interviews. Our findings related to Anglo women differ from those reported by Ugarriza, Brown, and Chang- Martinez (2007), who conducted qualitative interviews of Anglo women who had not experienced a self-identified postpartum depression. Among the pro- tective factors cited by researchers was a “special recognition” given to the mothers by spouses, family and community. Mothers in this study by Ugar- riza and colleagues commented on their new and enriched sense of purpose and of self. Most of these Anglo women, however, were older and more advantaged than those in our study. This contrast illustrates the potential moderating role that socioeconomic status may have within the psychoso- cial context of Anglo women.

The theme of energy and emotional demands involved with parenting found among African American mothers also was reported by Amankwaa (2003) in a qualitative study of African American women with diagnosed or self-reported postpartum depression. In that study, women reported that stressors related to caring for infants with colic and the care of other children in the family were among those that preceded a shift to a depressed mood during the postpartum period.

The pervasive context of family that was noted for Hispanic mothers is similar to others in that the extended and nuclear family is the primary source of support for foreign-born Hispanic mothers (Page, 2004). Hispanic mothers rely on their family members, particularly their own mothers, for emotional support and advice. The women in this study, however, were U.S.-born Hispanic mothers, who typically experience more stress and have a less healthy diet than their foreign-born Hispanic or Anglo counterparts (Page). The support that women in this study felt by just the presence of their family may indicate the psychological and relational tie some Hispanic women have to their family members.

POTENTIAL STRATEGIES FOR ETHNIC-SPECIFIC MATERNAL HEALTH PROMOTION PROGRAMS

The goal of this study was to describe ethnic differences in the psychoso- cial contexts in a group of low-income American new mothers to serve as a guide in developing ethnic-specific health promotion interventions, es- pecially related to reducing postpartum depressive symptoms and weight

52 B. Sterling et al.

retention from pregnancy. Customizing health promotion interventions that address ethnic-specific forces influencing low-income mothers’ context may improve program effectiveness. In a group of Anglo American women who are experiencing an altered sense of self, weight loss programs might in- clude management strategies that improve their self-image, such as getting dressed daily in properly fitting clothes and avoiding baggy pants and shirts. Strategies that promote introspection, such as journaling of feelings related to a sense of control also may be effective in reducing depressive mood (Gortner, Rude, & Pennebaker, 2006). Anglo mothers could use the journal as a “consciousness-raising” activity to record emotional difficulties they are experiencing, reflect on the meaning of these difficulties, and propose strate- gies to address them. Providing assertive training and establishing realistic goals for weight loss and processing perceptions of self-image also should be components of effective programs targeting Anglo women.

Health promotion programs for African American mothers who may be struggling with parenting demands may be more effective if held in a group setting, allowing mothers to talk with one another without interruption from children. African American mothers in our larger study were more likely not to be partnered than were Anglo and Hispanic mothers, thus locating health promotion programs along public transportation routes and providing on- site child care in a separate room would enhance the likelihood that these women would participate in programs. Discussion could focus on identifying and managing daily events that lead to negative emotions and unhealthy be- haviors, such as smoking, among African American women (Pletsch, 2006). Providing anticipatory guidance regarding realistic expectations for child be- havior and parenting skills are some stress management strategies that may be effective for these women. Facilitating the development of support groups and providing telephone follow-up calls also should be included in health promotion intervention programs targeting African American mothers.

The importance of inclusion of the immediate and extended family should frame health promotion programs targeting Hispanic mothers. Strate- gies for providing healthy meals and promoting physical activity for all fam- ily members could be discussed. Encouraging family members, particularly Hispanic women’s mothers, to attend the program meetings may decrease the hesitancy that Hispanic women feel when attending to their individual health needs and provides an opportunity to educate the family on healthy eating practices (Thornton et al., 2006). While meeting the needs of family members is an inherent practice for many Hispanic mothers, some may expe- rience increased stress when trying to meet family needs as well as their own health needs. Health promotion interventions that include time management strategies may be more effective. For example, Hispanic mothers could be encouraged to establish daily schedules that included time for attending to family and child care needs, as well as time for personal health-promoting activities.

Ethnic Context Affecting Weight Loss 53

Limitations

Participant selection was limited to those women who had completed all phases of a larger research study in the United States on thriving during postpartum and who had either retained weight or had experienced ele- vated depressive symptoms or both at 12 months postpartum. Thus, these women may not have been characteristic of low-income U.S.-born Anglo, African American, and Hispanic new mothers. Because of the eligibility cri- teria regarding BMI and scores on the CES-D, the ethnic-specific themes identified within this sample of low-income women may not be found in women with normal weight, who were not experiencing depressive symp- toms, or in an otherwise dissimilar sample. Furthermore, data collection was limited to participant responses and facilitators’ field notes obtained at the time of the focus group. No attempt was made to contact the participants after the completion of the focus groups; therefore, no further analysis to achieve data saturation was conducted.

Women’s Health Perspectives

New mothers may experience emotional and psychological stressors throughout the first year postpartum that alter their physical well-being and functioning and, thus, alter their sense of personal control. In our study the overarching theme of altered “perceived control” was manifested differently within ethnic groups and illustrates several implications. First among these is the varying burden that women carry related to child care and parenting. Parenting is more likely to be viewed as burdensome when women with low resources have pregnancies that are unintended (Ispa, Sable, Porter, & Csizmadia, 2007).

Second, this study supports the importance of exploring ethnic-specific themes in the formative stages of program development to increase the rele- vance of such programming. Although it is unclear to what extent the ethnic- specific themes found in this study are applicable in other countries and settings, the findings still serve to alert program planners to the importance of ethnic-specific considerations. In summary, the obesity epidemic (WHO, 2000) and concerns about mental health, especially in low-income countries (WHO, 2008), support the importance of programs to reduce occurrence of these two health conditions. The postpartum period is a transition interval during which women may be at risk of elevated depressive symptoms and weight gain. Consequently, study of ethnic differences in women’s postpar- tum psychosocial contexts that may affect the success of health promotion programs to reduce weight retention and postpartum depression is needed. Addressing the ethnic-specific forces that frame the context of these women’s lives during the postpartum period is critical for enhancing the effectiveness of interventions for low-income and ethnically diverse mothers.

54 B. Sterling et al.

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