Is Depression Associated with Contraceptive Motivations, Intentions, and Use Among a Sample of Low-Income Latinas?

Women's Health Issues 24-1 (2014) e105–e113

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Original article

Is Depression Associated with Contraceptive Motivations, Intentions, and Use Among a Sample of Low-Income Latinas? Diana N. Carvajal, MD, MPH a,*, Sharon R. Ghazarian, PhD b, Sarah Shea Crowne, PhD c, Pamela Bohrer Brown, BA d, Olivia Carter Pokras, PhD e, Anne K. Duggan, ScD f, Beth Barnet, MD c a

Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland Biostatistics, Epidemiology and Data Management (BEAD) Core, Center for Child & Community Health Research, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland c Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland d Maternal and Child Health and Multicultural Programs, Baltimore Medical System, Inc., Baltimore, Maryland e Department of Epidemiology and Biostatistics, University of Maryland College Park School of Public Health, College Park, Maryland f Department of Pediatrics, Health Policy and Management, Johns Hopkins University School of Medicine, Baltimore, Maryland b

Article history: Received 25 June 2013; Received in revised form 25 September 2013; Accepted 15 October 2013

a b s t r a c t Background: Latinas in the United States experience high rates of unintended pregnancy and low rates of contraception use, yet reasons are not completely understood. Depression is common among pregnant and nonpregnant Latinas; its influence on contraceptive motivations, intentions, and use is understudied. Objectives: We sought to 1) describe Latinas’ contraceptive motivations, intentions, and use; 2) use structural equation modeling to test associations between depression and contraceptive self-efficacy/motivations/intentions/use; and 3) determine whether associations differ by pregnancy status. Methods: This cross-sectional study included Latinas ages 15 to 45 recruited from an urban Federally Qualified Health Center in Baltimore, Maryland. Structured surveys were used to collect data regarding depressive symptoms measured using the PHQ-9. All other constructs were measured with previously validated questions. Constructs included contraceptive self-efficacy, positive and negative contraceptive motivations (perceived advantages and disadvantages of using contraception), contraceptive intentions to begin or continue contraception use, and contraceptive methods currently used. Results: Among pregnant Latinas, depression was associated with negative motivations (b ¼ 0.16; p < .05), negative motivations were associated with intentions (b ¼ 0.22; p < .01), and contraceptive self-efficacy was associated with intentions (b ¼ 0.43; p < .001). Among nonpregnant Latinas, contraceptive self-efficacy was associated with intentions (b ¼ 0.78; p < .001) and intentions were associated with use (b ¼ 0.40; p < .05). Conclusions: Among pregnant Latinas, negative motivations intervene in the association between depression and contraceptive intentions. For nonpregnant Latinas, intentions intervene in the association between self-efficacy and contraceptive use. This study underscores the importance of depression screening during pregnancy and encourages practitioners to target contraceptive motivations to improve contraceptive use. Copyright Ó 2014 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

An unintended or unplanned pregnancy is one that is either mistimed or unwanted at the time of conception (Santelli et al., 2003). Half of all pregnancies in the United States are unintended (Finer & Zolna, 2011), and occur most commonly * Correspondence to: Diana N. Carvajal, MD, MPH, Department of Family and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 1300 Morris Park Avenue, Mazer, 4th floor, Rm 414, Bronx, NY 10461. E-mail address: dcarvaja@montefiore.org (D.N. Carvajal).

among low-income, minority groups (Finer & Zolna, 2011). Among the poorest women, Latinas experience the highest rates of unintended pregnancy with a rate of 54% compared with 40% for non-Hispanic White women (Finer & Zolna, 2011; Guttmacher Institute, 2011). Unintended pregnancies are associated with high costs and adverse health outcomes, including poor prenatal health behaviors, prenatal care delay, and adverse maternal and child health (Cohen, 2008; Santelli et al., 2003). In 2008, one Medicaid-funded birth cost

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$12,613, whereas the per-person cost for contraceptive care was $257 (Trussell, 2010). Contraception is vital for prevention of unintended pregnancies (Centers for Disease Control and Prevention, 2013); half of all unintended pregnancies are among women not using contraception (Guttmacher Institute, 2008). Many Latinas, especially poor Latinas, do not use contraception consistently (Sterling & Sadler, 2009; Garces-Palacio, Altarac, & Scarinci, 2008). Reasons for nonuse among Latinas include lack of knowledge, low self-efficacy, limited access to care, low Englishspeaking ability, and cultural factors such as male domination, and religious beliefs (Frost & Driscoll, 2006; Garces-Palacio et al., 2008; Sterling & Sadler, 2009; Unger & Molina, 2000). Previous studies of Baltimore Latinos have also demonstrated similar obstacles to health care services, including language barriers, cultural issues, limited access to care (Martinez & Carter-Pokras, 2006; Martinez, Carter-Pokras, & Brown, 2009), religious beliefs, low literacy, health care system mistrust, and communication difficulties with health care providers (Carter-Pokras et al., 2008). Theoretical Framework for Understanding Contraceptive Behavior Theories of behavior can guide our understanding of the factors associated with contraceptive use. The theory of planned behavior posits that motivations are related to intentions, and both predict behavior (DiClemente, 1986). One key motivator is a person’s level of confidence or self-efficacy to carry out a health behavior successfully (Ajzen, 2002; Ajzen & Fishbein, 1972; DiClemente et al., 1991). The expanded health belief model puts forth that self-efficacy influences an individual’s intention to carry out health behaviors (Rosenstock, Strecher, & Becker, 1988). Finally, the transtheoretical model posits that decisional balance (measures perceived advantages and disadvantages of a health behavior, also known as positive and negative motivations) and self-efficacy are key variables associated with behavioral change (Ajzen & Fishbein, 1972; DiClemente et al., 1991). Both the health belief model and the transtheoretical model have been used previously to explain women’s perceptions about contraception (Brown, Ottney, & Nguyen, 2011). We posit a conceptual framework whereby contraceptive self-efficacy and positive/negative contraceptive motivations are associated with contraceptive intentions, and both are predictive of use. Pregnant women may have different contraceptive motivations and intentions than nonpregnant women. Pregnancy can be associated with emotional stress and even distress (Yu, McElory, Bullock, & Everett, 2011). The stress of pregnancy (Pawluski, van den Hove, Rayen, Prickaerts, & Steinbusch, 2011) may motivate some women to intend to use contraception immediately postpartum. Alternatively, pregnancy stress may lead to decreased self-efficacy and motivations for certain health behaviors, including contraception use. Because pregnancy can be a time of distinct emotional and behavioral fluctuation (Kinsley & Lambert, 2006; Leuner, Glasper, & Gould, 2010; Pawluski & Galea, 2008), we felt that pregnant women’s contraceptive self-efficacy, positive and negative contraceptive motivations, and contraceptive intentions should be considered separately from those of nonpregnant women. Role of Depression Depression, relatively common among Latinas (Davila, McFall, ndez, Das, Alfonso, Weissman, & & Cheng, 2009; Lewis-Ferna

Olfson, 2005; Munet-Vilaro, Folkman, & Gregorich, 1999), may confer risk for unintended pregnancy. Depression is also common among low-income, urban-dwelling, pregnant women (Hobfoll, Ritter, Lavin, Hulsizer, & Cameron, 1995) and pregnancy itself may increase depression risk owing to hormonal variations (Marcus, 2009). However, the specific role of depression in shaping contraceptive motivations, intentions, and behaviors is unknown. Some studies reveal that depression may be associated with low self-efficacy (Deal & Holt, 1998; Sacco & Bykowski, 2010) and may have a moderating effect on self-efficacy for some health behaviors (Kennard, Stewart, Hughes, Patel, & Emslie, 2006; Vuorimaa et al., 2008). Depression has also been associated with impaired motivation, risky sexual behaviors, and decreased contraception use (Kennard et al., 2006). Ultimately, depression may alter a woman’s contraceptive self-efficacy, positive/negative motivations, intentions, and use (Barnet, Liu, & DeVoe, 2008; Stewart, 2005). How and to what extent depression influences pregnant and nonpregnant Latinas’ contraceptive decision making is unknown. We used health behavior theory and empirical evidence to test the influence of depression on pregnant and nonpregnant Baltimore Latinas’ contraceptive self-efficacy, positive/negative motivations, intentions, and use. We hypothesized that 1) depressed women would report lower self-efficacy, fewer positive motivations, and more negative motivations for contraceptive use, 2) depressed women would report weaker contraceptive intentions, 3) intentions would be positively associated with selfreported contraceptive use, 4) contraceptive self-efficacy, and positive and negative contraceptive motivations would explain the association of depression with contraceptive intentions and use, and 5) lower self-efficacy, fewer positive motivations, and more negative motivations would be associated with weaker contraceptive intentions and decreased likelihood of contraceptive use. For pregnant women, the outcome of interest is contraceptive intention; for nonpregnant women, the outcomes are contraceptive intention and contraception use.

Methods Study Design, Participants, and Setting We conducted a cross-sectional study in which bilingual research assistants administered structured surveys to a sample of 15- to 45-year-old Latinas from June 2010 to January 2011. Women who did not identify as Latina and those younger than 15 or older than 45 years of age were excluded from the study. Participants were recruited during weekday office hours in the waiting area of the Highlandtown Healthy Living Center, a federally qualified health center serving a diverse population of low-income patients in Baltimore, Maryland. Potential participants were identified by providers and medical staff, and subsequently approached by research assistants. Of the 439 women approached, 369 (84%) agreed to participate; however, two were ineligible. The most common reason for refusal was lack of time. The total final sample was 364 (3 participants did not complete the survey). The final analytic sample was 338 (10 of the nonpregnant participants were not included for analysis of contraceptive motivations/intentions/use because they reported having tubal ligations, i.e., a sterilization procedure; 16 nonpregnant participants indicated that they were actively trying to get pregnant and thus were also excluded for analysis of contraceptive motivations/intentions/use).

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This study was approved by the University of Maryland School of Medicine and The Johns Hopkins University School of Medicine Institutional Review Boards. Data Collection and Measurement Research assistants ascertained that the participant identified as Hispanic/Latina, obtained written informed consent, and conducted the survey in either English or Spanish according to participant preference. Participants received $20.00 gift cards as compensation. Measures Demographic measures included birthplace, preferred language, and education level. Pregnancy status was also determined through self-report. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ-9), a nine-item instrument predictive of depression (Arroll et al., 2010; Kroenke, Spitzer, & Williams, 2001; Richardson et al., 2010) and validated among both English and Spanish speaking Latinas (Merz, Malcarne, Roesch, Riley, & Sadler, 2011). The PHQ-9 assesses depressive symptoms over the previous 2 weeks with nine items based on the DSM IV-R criteria for depression and scored on a 3-point scale: 0 ¼ not at all; 1 ¼ several days; 2 ¼ more than half the days; 3 ¼ nearly every day (Arroll et al., 2010; Kroenke et al., 2001; Richardson et al., 2010). Scores range from 0 to 27 with a score of greater than 10 indicating depression (Merz et al., 2011). To increase sensitivity, we used the two-step scoring procedure described by Arroll and colleagues (2010). First, we identified participants who scored greater than zero on the PHQ-2, the first two items of the PHQ-9: (“Over the past 2 weeks, how often have you been bothered by: 1.”Little interest or pleasure in doing things” or 2. “Feeling down, depressed, or hopeless”). For those with a response greater than 0 on either item, we administered the full PHQ-9 to determine depression. Participants scoring a zero on the PHQ-2 were considered not depressed. Contraceptive self-efficacy was measured with a validated six-item scale assessing women’s confidence in their ability to either avoid sex or use contraception in different situations (Cabral et al., 2004; Galavotti et al., 1995; Lauby et al., 1998). These questions were initially developed to measure self-efficacy for condom use and other contraceptive use among high-risk women (HIV positive or at high risk for sexually transmitted infections). For example, “How confident are you that you could put off sex if you didn’t have a condom with you or weren’t using some form of birth control?” Responses were scored on a 5-point scale from 5 ¼ very sure I could to 1 ¼ very sure I could not. Positive and negative contraceptive motivations were assessed using a decisional balance scale to measure contraception use (Galavotti et al., 1995; Lauby et al., 1998). Decisional balance assesses the balance between perceived advantages and disadvantages of a particular behavior (Lauby et al., 1998). Again, the questions used in this study were initially used to measure decisional balance for condom use and other contraceptive use among high-risk women (HIV positive or at high risk). Decisional balance was measured using a three-item additive scale assessing perceived advantages of using contraception and a nine-item additive scale assessing perceived disadvantages of using contraception (Galavotti et al., 1995; Lauby et al., 1998). The more positive the motivation for using contraception, the higher the score on the positive motivations scale. The more negative

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the motivation toward using contraception, the higher the score on the negative motivations scale. Contraceptive intentions were assessed by asking nonpregnant participants the likelihood of starting “to use or continue to use some type of birth control all of the time to keep from getting pregnant?” Pregnant participants were asked about contraceptive intentions for the immediate postpartum period. Responses ranged from 1 ¼ very sure you will not use birth control to 5 ¼ very sure you will (Cabral et al., 2004). nonpregnant participants who reported a current desire for pregnancy (i.e., those who responded yes to “Are you trying to get pregnant now?”) were not asked about their contraceptive intentions. Contraceptive use was measured by asking participants whether they were currently using contraception (yes/no). If respondents answered yes, they were asked to select their method(s) from a comprehensive list. Of note, the self-efficacy and decisional balance scales are not validated in Spanish. These scales were professionally translated from English to Spanish then backtranslated (from Spanish to English) by an experienced, native Spanish-speaking health services researcher who specializes in the translation of such scales to Spanish. Accuracy of the translations were then confirmed and agreed upon by the lead author, who is also a native Spanish speaker. The survey also included some items from the Pregnancy Risk Assessment Monitoring System, a population-based surveillance system of maternal behaviors and experiences before, during, and after pregnancy (Centers for Disease Control and Prevention, 2011). Pregnancy Risk Assessment Monitoring System questions that were asked in the study included questions about current and prepregnancy weight, prenatal care, plans for breastfeeding, and use of alcohol/tobacco, but none of these factors (other than pregnancy intentions) were included as part of the analysis. Nonpregnant participants who reported a firm intention to become pregnant were specifically excluded from analysis of contraceptive self-efficacy, motivations, and use. The final questionnaire was pilot tested in the field with approximately 20 English- and Spanish-speaking Latinas over the course of several weeks before study commencement. Analysis Analyses were completed using structural equation modeling (SEM) in MPlus 6.12 (Muthen & Muthen, 2010), a range of multivariate techniques that are used to examine underlying relationships or structures among variables in a model (Buhr, Goodson, & Neilands, 2007). Preliminary analyses examined the factor structure of continuously measured study variables (depression, contraceptive self-efficacy, contraceptive motivations) using a confirmatory factor analysis (CFA) approach. Measurement models were specified based on existing literature such that all nine PHQ9 items were loaded onto one latent variable, all six items for the contraceptive self-efficacy scale were loaded onto one latent variable, and the contraceptive motivations items were split into two latent variables for positive and negative motivations. The strength of factor loadings (indicates reliability) and general model fit (indicates validity) were examined for each CFA model (one for each latent variable). CFA models were also examined by pregnancy status to determine whether results were robust across groups. Pregnant and nonpregnant women were kept in separate models given the likely differences in their contraceptive motivations/intentions (as mentioned previously); also, use could obviously only be

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examined in nonpregnant women. Items demonstrating factor loadings of less than 0.33 were considered a poor fit for the latent variable and were excluded from subsequent analyses. Model fit was assessed with the comparative fit index and the root mean square error of approximation. Models demonstrating a comparative fit index of greater than 0.90 and an root mean square error of approximation of less than 0.08 were deemed to fit the underlying data well, whereas models with a comparative fit index of greater than 0.95 and an root mean square error of approximation of less than 0.05 suggested a very good fit (Browne & Cudeck, 1993; Hu & Bentler, 1999). Preliminary analyses indicated that latent variables could be specified for contraceptive self-efficacy and negative contraceptive motivations. Contraceptive self-efficacy is a latent variable specified with five items (removed item, “How confident are you that you could use a condom or some other form of birth control if you were using drugs and alcohol?” for low loadings; a ¼ 0.83). Items for the contraceptive motivations construct suggested poor fit when specified as three items for positive motivations and nine items for negative motivations. CFA analyses suggested a good fit with a latent negative motivations variable specified with four items (a ¼ 0.72). Positive contraceptive motivations were specified as a single item summary score based on two items (Do you think using birth control lets you have sex without worrying about getting pregnant?; Do you think using birth control keeps your partner from worrying about you getting pregnant?; r ¼ .62). These decisions were robust for both pregnant and nonpregnant women. The remaining items were not used in subsequent analyses because preliminary analyses did not demonstrate adequate reliability and validity. A manifest summary variable was created for depression (based on a summary score of responses from all nine items when one of the first two items was nonzero; a ¼ 0.78), because the latent variable did not demonstrate adequate fit. Contraceptive intentions and contraceptive use were included as binary manifest variables. Figure 1 provides a list of all of the items (by variable) used in to construct latent and manifest variables as detailed above. Scales for latent constructs were set by using effectscoding methodology to ensure that latent variable estimates are in the metric of observed variables and, thus, have meaningful interpretations (Little, Slegers, & Card, 2006). Mediation models were tested by examining the joint significance of paths leading to and from the intervening variables of interest (MacKinnon, Lockwood, Hoffman, West, & Sheets, 2001). Adequate reliability for study variables was demonstrated with Cronbach’s alpha coefficients and/or correlation coefficients as reported above. Convergent and discriminant validity were examined for study variables using additional data for variables that are not included in the current study. Depression and negative motivations demonstrated convergent validity when associated in expected directions (r ¼ 0.28; p < .001 for depression; r ¼ 0.12, p < .05 for negative motivations) with intimate partner violence (a non–study-related variable that was measured using the validated conflict tactics scale 2-revised, a series of subscales that measure physical assault, sexual coercion, and psychological aggression by a partner) for the full sample (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). Convergent validity was demonstrated for contraceptive selfefficacy in association with a single item that asks participants whether important persons in their lives support contraception (r ¼ 0.13; p < .05). Although validity was not demonstrated for positive motivations with the data available for this study, the variable was kept in the model because the items are part of the

whole decisional balance scale which measures perceived advantages and disadvantages of using contraception (i.e., motivations), an essential element of the transtheoretical model (DiClemente et al., 1991). Power estimation for SEM depends on the number of parameters, location of parameters of interest, model complexity, magnitude of misspecified parameters, indicator reliability, and sample size (MacCallum, Browne, & Sugawara, 1996; Preacher, Cai, & MacCallum, 2007). Examining power for both the pregnant and nonpregnant models, the current sample sizes achieve power of greater than 0.90 for testing a hypothesis of close fit (a ¼ 0.05; 53 degrees of freedom for each model). Missing data were minimal (average of 3.2% missing data across all study variables), and were handled using full information maximum likelihood methodology within SEM. Final hypothesis testing models are depicted in Figures 2 and 3 for pregnant and nonpregnant women separately. All hypothesis testing models include age as a covariate. Of note, the authors did consider the possibility that the relationship between contraceptive self-efficacy, intentions, and use might differ by contraceptive method. However, there was not enough variation in chosen method or enough of a sample size to include method type in the SEM. Results Sample Attributes Table 1 provides sample sociodemographic characteristics of the entire sample (n ¼ 364) by pregnancy status. Sixty-four percent of participants were pregnant at the time of interview. Pregnant women were older than nonpregnant women (mean age 28.7 vs. 26.4 years; p < .001). Participants were born in 18 different countries; most were from Mexico, El Salvador, or Honduras. Nearly all of the interviews were conducted in Spanish per participant request. Eighty-four percent of nonpregnant women and 92% of pregnant women were uninsured, whereas 56% of nonpregnant women and 64% of pregnant women did not have a high school diploma or equivalent (GED) at the time of interview. Table 2 gives sample statistics related to depression, contraceptive self-efficacy, positive/negative motivations, intentions, and use. Among both pregnant and nonpregnant women, 13% and 15%, respectively, met criteria for depressive symptoms (PHQ-9, 10) using the two-step process. There was no difference between the two groups. Of the 133 nonpregnant participants, approximately 7% reported having tubal ligations and 12% indicated that they were actively trying to get pregnant. Questions regarding contraceptive self-efficacy, motivations, intentions, and use were only asked of nonpregnant participants who did not report tubal ligations and who did not desire pregnancy at the time of survey administration (final sample of nonpregnant participants ¼ 107). Only about one third of both pregnant and nonpregnant women reported they were “very sure” about their ability to use contraception in all presented scenarios. For both pregnant and nonpregnant women, the mean score for positive contraceptive motivations was approximately 8, and the mean score for negative contraceptive motivations was 13.6 for pregnant women and 13.3 for nonpregnant women. Seventyeight percent of pregnant participants reported intentions to use contraception after delivery, whereas 73% of nonpregnant participants reported intentions to use or continue to use contraception. Among nonpregnant women who did not desire

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Figure 1. Items used in preliminary and final analyses of latent/manifest variables.

pregnancy, 76% reported current use of contraception. The most popular form of contraception for current users was DepoProvera (39%), followed by condoms (17%), and oral contraceptives (14%).

for pregnant women, suggests an indirect effect for the associaported that they wanted to avoid being pregnancy or were unsure (pregnancy intentions). Pregnancy intentions were also examined on a continuum of five possible responses (from “I really wanted to get pregnant” to “I really wanted to avoid

Hypothesis Testing Models Figure 2 displays the associations among depression, contraceptive self-efficacy, positive/negative contraceptive motivations, and contraceptive intentions for pregnant women. Depression was significantly associated with negative contraceptive motivations (b ¼ 0.16; p < .05); pregnant women who reported higher levels of depression reported more disadvantages of using contraception. Negative contraceptive motivations were also associated significantly with contraceptive intentions (b ¼ 0.22; p < .01); women who indicated more disadvantages of using contraception had weaker contraceptive intentions. The association between depression and negative motivations, and between negative motivations and contraceptive intentions

Figure 2. Final hypothesis-testing model pregnant women (n ¼ 231).

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women, results suggest contraceptive intentions function as an intervening variable in the association between contraceptive self-efficacy and contraceptive use. The indirect effect was further examined with the Sobel test and found to be significant (z ¼ 0.31; p < .05). Discussion

Figure 3. Final hypothesis-testing model for nonpregnant women (N ¼ 107).

getting pregnant”). There were no changes in substantive results for either group of women. Additionally, no differences in mean levels of depression were noted across groups. Figure 3 displays the associations among depression, contraceptive self-efficacy, positive/negative contraceptive motivations, contraceptive intentions, and contraception use for nonpregnant women. For nonpregnant women (not desiring pregnancy), there was a significant positive association between contraceptive selfefficacy and contraceptive intentions (b ¼ 0.78; p < .001) just as there was for pregnant women. Women who reported higher contraceptive self-efficacy had stronger intentions to use contraception. Contraceptive intentions were significantly associated with contraceptive use (b ¼ 0.40; p < .05); women with stronger contraceptive intentions were also more likely to report using contraception. Given the association between contraceptive self-efficacy and intentions, and the significant association between contraceptive intentions and use for nonpregnant

Table 1 Sample Sociodemographic Characteristics Characteristic

Percent with Characteristic or Mean Nonpregnant (N ¼ 133)

Age (y) <20 2 20–24 32 25–29 32 30–45 34 Mean age, y 28.7 (15–45) (range) Birthplace Ecuador 6 El Salvador 30 Dominican 3 Republic Guatemala 5 Honduras 14.5 Mexico 28 Puerto Rico 3 United States 4.5 Other* 5 Language of survey Spanish 96 Uninsured 84 Education Less than high 56 school

Pregnant (N ¼ 231) 11 22 42 25 26.4 (15–42)

Difference p Value

< .001

2 26.5 0.5 12.5 19 33.5 0 2.5 4.5 97 92

.49 .05

64

.12

* For nonpregnant women, the category of “other” includes Colombia, Nicaragua, Peru, Spain, Uruguay, and Venezuela. For pregnant women, the category of “other” includes Argentina, Bolivia, Nicaragua, Panama, Peru, and Saint Martin.

In this convenience sample of Baltimore Latinas, we found that pregnant women with depressive symptoms were more likely to report negative contraceptive motivations and thus weaker contraceptive intentions than their nondepressed counterparts. Nonpregnant women who reported more contraceptive self-efficacy were more likely to report stronger contraceptive intentions and actual contraceptive use than their less self-efficacious counterparts. Screening positive for depressive symptoms seems to enhance negative contraceptive motivations among pregnant women, but does not have an impact on positive contraceptive motivations. Additionally, depressive symptoms diminish participants’ intention to use contraceptives but do not affect contraceptive self-efficacy. Reasons for the lack of association of depressive symptoms with positive contraceptive motivations or with contraceptive self-efficacy are unclear. Although pregnant women with depressive symptoms recognize the benefit of contraception (mean score for positive motivations, 7.9; range, 3–9), they seem to be inclined to have more negative motivations toward contraception compared with their nonpregnant depressed counterparts. The frequency of high scores for each of the questions on the negative motivations scale was higher for pregnant depressed women vs. nonpregnant depressed women (for question 1 on the negative motivations scale, the frequency of nonpregnant depressed participants scoring 3 was 18% vs. 28% for pregnant depressed participants; for question 2, it was 9% vs. 18%, respectively; question 3: 11% vs. 25%, respectively; question 4: 7% vs. 20%, respectively). However, because these pregnant, depressed women still maintain recognition of the positive aspects of contraception (i.e., positive motivations regarding contraception), it is possible that their self-efficacy is subsequently unaffected. In contrast, although depressive symptoms do not seem to be a factor for contraceptive decision making among nonpregnant women, our model shows that contraceptive self-efficacy is associated with intentions, which, in turn, are associated with actual use. These findings corroborate our hypothesis and are concordant with several health behavior theories and previous studies that have shown an association between low self-efficacy and contraception nonuse. Although the lack of association with depressive symptoms for nonpregnant women is surprising, perhaps there is something inherent about depressive symptoms in pregnancy that specifically affects negative contraceptive motivations and subsequent intentions for use. Pregnant women are a unique group, and may have additional anxieties and burdens that are less common among nonpregnant women. For example, compared with nonpregnant depressed participants, depressed pregnant women were more inclined to report a higher frequency of negative motivations related to contraception interfering with sexual enjoyment. Another possible explanation for differences in the models for pregnant and nonpregnant women relates to the measures used for assessing positive and negative contraceptive motivations. Because our model did not show a clear association between both positive and negative motivations and the other variables

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Table 2 Depressive Symptoms, Contraceptive Self-Efficacy/Motivations/Intentions/Use by Pregnancy Status Variable

Difference* p Value

Percent with Characteristic or Mean Nonpregnanty (N ¼ 107)

Pregnant (N ¼ 231)

15 25.7 28 8.2 13.3 73 76

13 25.9 30 7.9 13.7 78 —

z

Depressive symptoms Depressed (PHQ-9 10) Contraceptive self-efficacy,x mean Contraceptive self-efficacy,k (“very sure”) Positive contraceptive motivations,{ mean Negative contraceptive motivations,# mean Intentions to use/continue to use contraception Current contraception use

.99 .73 .65 .11 .44 .89 —

Differences were computed using t-tests and chi-square statistics. Sample size is 107 here because, of the 133 nonpregnant participants, 16 (12%) indicated that they were actively trying to get pregnant and 10 (w7%) reported having bilateral tubal ligations (sterilization). Questions about contraceptive self-efficacy, positive/negative motivations, intentions, and use were thus not asked of participants who were actively trying to get pregnant or who reported tubal ligations (which are considered to be permanent contraceptive methods). z The statistic for depressive symptoms is reported here only for nonpregnant participants not desiring pregnancy and those who did not report tubal ligation. However, among all nonpregnant women (n ¼ 133), 14% met criteria for depression (PHQ-9  10). x Actual and possible score range is 6 to 30. k Participants who reported being “very sure” about their ability to use contraception in all presented scenarios. { Actual and possible score range is 3 to 9. # Actual score range is 9 to 27; possible score range is 3 to 27. * y

for either group of women, it may be that the decisional balance scale questions, particularly the positive motivations items (recall that validity was not demonstrated for positive motivations with the data available for this study), are simply unsuitable for this group of women as a whole. The majority of participants preferred to have the survey administered in Spanish, and as of yet, this scale has not been validated Spanish speakers. Furthermore, only 39% of our study participants reported a high school education or higher, mirroring the education statistics of Latinos in Baltimore city, yet substantially lower than national reports. Nationwide, 61% of Latinos report having a high school education or greater (Baltimore City Department of Health, 2011). Although the decisional balance scale has been validated in other languages among several populations (Blaney et al., 2012; Hoeppner et al., 2012; Chen, Sheu, Percy, Brown, & Yang, 2006), the questions may not have been culturally or educationally appropriate for this study’s sample of mostly Spanish-speaking women with limited education. Strengths and Limitations A major strength of this study is that it is among the first to use SEM to examine the interactive effects of contraceptive selfefficacy, motivations, intentions, and use with depression as a predictor. SEM methodology increases the likelihood that study results are precise and free from random error. A distinct advantage of SEM over traditional, regression-based approaches is the ability to account for measurement error in models and thus remove potential measurement bias from study results. SEM analysis also provides multiple fit indices to test model fit, decreasing the likelihood of model misspecification (Little, Bovaird, & Card, 2007). Additionally, the use of the validated depression scale and contraceptive self-efficacy items also add strength to the study. This study adds to the small body of reproductive health research that has been conducted with low-income, immigrant Latinas. Additionally, our study includes perspective about the contraceptive views of both pregnant and nonpregnant women. This is especially important as the Latino population continues to grow and will need culturally appropriate health care. By focusing on these Latinas, we have begun to examine a rapidly

growing group that is likely to continue to seek health care in the years ahead. Study limitations include its cross-sectional design, limiting conclusions about causality. Additionally, potentially important factors for Latinas’ contraceptive decision making were not included (e.g., family influences, cultural issues such as male domination and religious beliefs, health care system mistrust, communication with providers, political ideologies, and health literacy). Still, when considering the concept of male domination, it is important to note that the decisional balance items (positive/ negative motivations) do take into account whether a woman’s sense of control or her partner’s participation in contraceptive use, influence her motivations (Figure 1). The contraceptive selfefficacy scale also asks whether a woman would use contraception even if her partner were angry or refused to use it (Lauby et al., 1998). Also, participants’ personal beliefs (not specifically identified as cultural or religious) were also considered as part of the decisional balance questions (Figure 1). Last, because this study was conducted with a sample of mostly low-income participants, our findings may not reflect the perspectives of higher income Latinas who have private or employer-sponsored health insurance. Generalizability of results is limited. Overall, this is an important exploratory study that aims to crystallize several important psychological and behavioral constructs relevant to contraceptive behavior among a hard-toreach, at-risk, minority population. In the future, it will be important to address the specific factors that may influence Latinas’ contraceptive decision making but that were not included in this study (e.g., family influences, cultural issues, health care system mistrust, communication with providers, and health literacy). Longitudinal studies that assess contraceptive motivations, intentions, use, and unintended pregnancy rates over time are also needed. Implications for Practice and/or Policy Prevention of unintended pregnancy is a Healthy People 2020 objective (Healthy People 2020, 2011). In this study, we sought to build a framework to deepen our understanding of how contraceptive self-efficacy, positive/negative motivations, intentions, and use are related and how depression might

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influence these factors among both pregnant and nonpregnant Latinas, a high-risk group for unintended pregnancy. Our findings have implications for clinical practice. That pregnant Latinas with depressive symptoms were more likely to report negative contraceptive motivations and thus weaker contraceptive intentions than nondepressed pregnant Latinas underscores the importance of depression screening with appropriate intervention during pregnancy. For nonpregnant Latinas, the associations between contraceptive self-efficacy, intentions, and use suggest that practitioners might consider focused counseling aimed at enhancing self-confidence for contraceptive use. Still, it is important to emphasize the exploratory nature of this study, which can serve as a building block for future work but is not yet translational. A prospective longitudinal study that examines whether depression predicts contraception use and unintended pregnancy over time might shed further light on the observed relationships in this cross-sectional study. Additionally, it would be important to include data on chosen contraceptive method and consistency of method use in such a study. Data that improve our understanding of Latinas’ contraceptive self-efficacy, positive/negative motivations, and behaviors will help to inform effective interventions for the prevention of unintended pregnancy. Acknowledgments This research was supported by the American Academy of Family Physicians Foundation, The Thomas Wilson Sanitarium for the Children of Baltimore, and by Grant T32HS017596 from the Agency for Healthcare Research and Quality, which supports the family health services research training program in which Dr. Carvajal was a postdoctoral fellow. The authors gratefully acknowledge Grant APRPA006010, the Family Health Services Research NRSA training program grant funded by the Agency for Healthcare Research and Quality, and the Highlandtown Healthy Living Center staff members for their time, effort, guidance, and patience with this project. Salary support for Olivia D. CarterPokras from the Prevention Research Centers Program, Centers for Disease Control and Prevention (cooperative agreement 1 U48 DP001929). The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The corresponding author, Diana N. Carvajal, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. References Ajzen, I., & Fishbein, M. (1972). Attitudes and normative beliefs as factors influencing behavioral intentions. Journal of Personality and Social Psychology, 21(1), 1–9. Ajzen, I. (2002). Perceived behavioral control, self-efficacy, locus of control, and the theory of planned behavior. Journal of Applied Social Psychology, 32, 665–683. Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., et al. (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Annals of Family Medicine, 8(4), 348–353. Baltimore City Department of Health. (2011). The health of Latinos in Baltimore City 2011. Office of Epidemiology and Planning at the Baltimore City Health Department. Retrieved Oct 25, 2011, from: http://baltimorehealth.org/press/ 2011_10_20_Health_of_Latinos_Report_ENG.pdf. Barnet, B., Liu, J., & DeVoe, M. (2008). Double Jeopardy: Depressive symptoms and rapid subsequent pregnancy in adolescent mothers. Archives of Pediatrics and Adolescent Medicine, 162, 246–252. Blaney, C. L., Robbins, M. L., Paiva, A. L., Redding, C. A., Rossi, J. S., Blissmer, B., et al. (2012). Validation of the measures of the transtheoretical model for exercise in an adult African-American sample. American Journal of Health Promotion, 26(5), 317–326.

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Author Descriptions Dr. Sharon R. Ghazarian, PhD, is and Assistant Professor in the Department of Pediatrics at Johns Hopkins University School of Medicine. She is director of the Biostatistics, Epidemiology and Data Management Core in the Center for Child & Community Health Research.

Dr. Sarah Shea Crowne, PhD, is a research associate in the Department of Pediatrics at the Johns Hopkins University School of Medicine.

Ms. Pamela Bohrer Brown is the director of Maternal and Child Health and Multicultural Programs in the Baltimore Medical System, Inc.

Dr. Olivia Carter Pokras, PhD, is an Associate Professor in the Department of Epidemiology and Biostatistics at the University of Maryland College Park School of Public Health.

Dr. Anne K. Duggan, ScD, is a Professor of Pediatrics and of Health Policy and Management at the Johns Hopkins University School of Medicine.

Dr. Beth Barnet, MD, is a Professor of Family Medicine and also the Vice Chair of Research in the Department of Family and Community Medicine at the University of Maryland School of Medicine.