Archives of Psychiatric Nursing 28 (2014) 305–313

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The Roles of Social Support in Helping Chinese Women with Antenatal Depressive and Anxiety Symptoms Cope With Perceived Stress Ying Lau a, b,⁎, Daniel Fu Keung Wong c, Yuqiong Wang d, Dennis Ho Keung Kwong e, Ying Wang d a

Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore School of Health Sciences, Macao Polytechnic Institute, Macao, China Department of Applied Social Studies, College of Liberal Arts and Social Sciences, City University of Hong Kong, Hong Kong, China d Chengdu Women's and Children's Central Hospital, Chengdu, China e School of Health Sciences, Macao Polytechnic Institute, Macao, China b c

a b s t r a c t A community-based sample of 755 pregnant Chinese women were recruited to test the direct and moderating effects of social support in mitigating perceived stress associated with antenatal depressive or anxiety symptoms. The Social Support Rating Scale, the Perceived Stress Scale, the Edinburgh Depressive Postnatal Scale and the Zung Self-Rating Anxiety Scale were used. Social support was found to have direct effects and moderating effects on the women's perceived stress on antenatal depressive and anxiety symptoms in multiple linear regression models. This knowledge of the separate effects of social support on behavioral health is important to psychiatric nurse in planning preventive interventions. © 2014 Elsevier Inc. All rights reserved

Pregnancy is a time for celebration of the arrival of a new member in the family but it is also a time of conspicuous changes to the expecting mother's body, lifestyles, roles, relationships and responsibilities (Guardino & Schetter, 2013; Razurel, Kaiser, Selienet, & Epiney, 2013). Profound changes can trigger stress in pregnant women (Cardwell, 2013; Lazatus & Folkman, 1984). Stress during pregnancy has been associated with increased incidence of antenatal depressive (Razurel et al., 2013) or anxiety (Roos, Faure, Lochner, Vythilingum, & Stein, 2013) symptoms. Depression and anxiety during pregnancy are major public health problems with prevalence report as high as 70% of pregnant women experience either depressive or anxiety symptoms during pregnancy (Ali, Azam, Ali, Tabbusum, & Moin, 2012). Thus, it is important to consider ideas for interventions that might be effective in reducing symptoms of anxiety, depression, or both. Psychosocial stress theory identifies social support as a protective factor against depressive (Jeong et al., 2013) and anxiety (Aktan, 2012) symptoms during pregnancy. Although social support during the antenatal period appears to be a major factor related to the psychological health of pregnant women (Razurel et al., 2013), the specific role of social support on psychological health remains unclear (Ibarra-Rovillard & Kuiper, 2011). China has experienced profound economic and social development in the last two decades, and, like many countries of today's fastpaced world, perceived stress and antenatal depressive and/or anxiety symptoms have become more prevalent, thus becoming a matter of ⁎ Corresponding Author: Ying Lau, PhD, MN, BN (Hon), BSc, IBCLC, RM, RN, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. E-mail address: [email protected] (Y. Lau). http://dx.doi.org/10.1016/j.apnu.2014.05.009 0883-9417/© 2014 Elsevier Inc. All rights reserved

utmost concern to health-care policy makers (Lau, 2013; Lau, Yin, & Wang, 2011). It is important to identify the mechanisms through which social support might be protective against the development of antenatal depressive and anxiety symptoms. Therefore, this study sought to enhance knowledge by examining the direct and moderating effects of social support on the relationship between perceived stress and antenatal depressive and anxiety symptoms. DIMENSIONS OF SOCIAL SUPPORT Social support is considered a meta-construct and as such, it has no single, simple definition (Gottlieb & Bergen, 2010). Social support, in general, is a resource that people use to cope with stress and improve psychological adaptation (Rubens, Vernberg, Felix, & Canino, 2013) as well as maintain functional ability (Wilson, Washington, Engel, Ciol, & Jensen, 2006). Support can provide reassurance, clarification, discussion and stability during stressful events (Nguyen, Kohorn, Scgulman, & Colson, 2012). We propose that the relationship between perceived stress, social support and antenatal depressive or anxiety symptoms can be considered within the psychoneuroimmunology (PNI) framework (McCain, Gray, Walter, & Robins, 2005). The mechanisms of the PNI are focused on the multidimensional physiological and pathophysiological interactions and this framework incorporates neuroendocrine–immune processes underlying biological adaptation and physical health (McCain et al., 2005). The PNI framework suggested that the roles of social support can change perceived stress related responses and improve the psychological outcomes of antenatal depressive or anxiety symptoms (McCain et al., 2005).

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The concept of social support may be viewed differently in different cultures (Stanaway et al., 2011), and so to understand how people appraise their social relationships, a culturally-sensitive assessment tool is necessary (Tonsing, Zimet, & Tse, 2012). In response to this consideration, a number of Chinese theorists have developed the Social Support Rating Scale (SSRS) tested on and validated for use on Chinese populations that focuses on the subjective–objective dimension and support availability (Xiao, 1999; Xie, He, Koszycki, Walker, & Wen, 2009). Subjective support deals with the individual's subjective experience of an expected availability—not its actual materialization—where trust in a mobile support system is feasible within an individual's interpersonal network (Xiao, 1999). On the other hand, objective support reflects the degree of practical support the social network is able to provide (Xiao, 1999; Xie et al., 2009). The availability of support refers to the accessibility and effectiveness of social support to an individual for dealing with a life event (Xiao, 1999). Subjective support is based primarily on one's history of having received effective objective support (Lakey & Orehek, 2011). Conceptually, subjective support is more closely linked to the intrapersonal approach, and objective support and support availability are more likely to represent a situational factor that is closely related to the interpersonal approach (Uchino, 2009). Although subjective support has been found to be more determinative and valuable than objective support on behavioral health in Western literature (Gottlieb & Bergen, 2010; Gulacti, 2010), the applicability of these findings to Chinese populations is still in question.

Dupanloup, Irion, & Epiney, 2011), thus making negative consequences less likely (Andreotti et al., 2013). In this sense, social support may intervene between the experience of stress and the onset of a pathological outcome by reducing a person's reactiveness to the perceived stress (Cohen & Wills, 1985). Social support appears to decrease the intensity of one's perception of crises or to aid one in acquiring the means and skills required to buffer the effects of stressors (Kingston et al., 2012). However, the empirical evidence for the moderating effects of social support has been mixed (Lewis, Byrd, & Ollendick, 2012; Sirin et al., 2013). Although a few studies have found that social support has a moderating effect on the development of psychological problems among pregnant women (Lau & Wong, 2008; Pires, Araujo-Pedrosa, & Canavarro, 2013), the relationship between social support and antenatal depressive and anxiety symptoms requires further examination. The purpose of this study was to expand our knowledge about social support and mental health among pregnant Chinese women. The study's objectives were to examine the direct and moderating effects of social support in the presence of stress on antenatal depressive and anxiety symptoms, and to compare the effects of objective support, subjective support and support availability on antenatal depressive and anxiety symptoms among a convenience sample of pregnant Chinese women. Identification of the separate effects of social support on mental health may suggest more effective interventions to reduce these symptoms on pregnant women.

Direct Effect of Social Support on Antenatal Depressive and Anxiety Symptoms

Design

In the direct effects model, a predictor of social support is directly related to its outcome, and its mode of action does not involve any intermediate variable (Wills & Fegan, 2001). For instance, a study has found that social support has a direct effect on people's mental health, that is, people with lower social support have poorer mental health than those with higher social support, regardless of the stress levels (Cohen & Wills, 1985). The perinatal literature has found lack of social support to be an important and consistent risk factor for antenatal depressive (Jeong et al., 2013) and antenatal anxiety (Aktan, 2012) symptoms. Because lack of support constitutes a stressor in and of itself, there may be a negative stressor–support correlation (Kingston, Heaman, Fell, Dzakpasu, & Chalmers, 2012). The core idea of the direct effects model is that social support may be related to mental health outcomes through psychosocial mechanisms (Thoits, 2011) or neuroendocrine system functioning (Hostinar & Gunnar, 2013). Notably, the relations between anxiety symptoms, stress and social support have received less attention compared with the relations between depressive symptoms and stress and social support in the literature (Aktan, 2012). In addition even fewer studies have simultaneously investigated the direct effects of social support on depressive and anxiety symptoms during pregnancy. Therefore, whether social support has a direct effect on antenatal depressive and anxiety symptoms is worthy of further research. Moderating Effect of Social Support on Antenatal Depressive and Anxiety Symptoms The moderating model conceptualizes that social support may protect individuals facing high levels of stress from experiencing stress-related symptoms, such as depressive and anxiety symptoms (Gottlieb & Bergen, 2010). These moderating effects may alter people's perceptions of negative events, transfer their coping resources, facilitate changes or provide solutions to people in terms of encouraging changes in people's adaptive responses to healthrelated behaviors (Cohen & Wills, 1985; Razurel, Bruchon-Schweitzer,

METHODS

This research is an exploratory cross-sectional quantitative study. The study was approved in April 2012, and a pilot study with 100 subjects was carried out for a month in a setting similar to the main study's and on a similar population. The pilot study examined the reliability, validity and feasibility of the methods of measurement in the target population. On the basis of the comments received, some of the demographic and obstetric items were revised without changing their meanings to make the items more accessible. Setting and Sampling The research setting was Chengdu, a sub-provincial city located in south-western China and the capital of Sichuan province. Chengdu is one of the most important economic centers and transportation and communication hubs in the region, and it covers an area of 12.3 thousand square kilometres (4749 mile 2) with a population of over 11 million. The study was approved by the institutional review board of a regional public hospital in Chengdu which serves an obstetric population of over 204,096 women annually and delivers about 12,000 babies per year (Chengdu Women & Children's Central Hospital, 2013). Despite the fact that recruitment was conducted at this hospital, the sample is nonetheless community-based, and is representative of pregnant women in the general population, as women from different regions of Chengdu that covered different demographic and socio-economic divisions were included in this study. Assuming that the prevalence of stress in the sample population is the same as that found in a previous study (Kok et al., 2013), which was ± 1.98%, a sample size of 755 would achieve a low error factor (Altman, 2006). This degree of error is approximately one quarter of the size of the prevalence estimate, and is therefore sufficiently small to use with confidence for planning purposes in the health-care service system. A community sampling with a sample size of 755 antenatal women was used, which was considered adequate for the detection of women experiencing stress. Non-probabilistic convenience sampling was adopted because of resource constraints. The inclusion criteria included (1) primiparae or multiparae;

Y. Lau et al. / Archives of Psychiatric Nursing 28 (2014) 305–313

(2) of ≥ 18 years of age; and (3) with ability to read and write in Chinese in order to complete the questionnaires. The exclusion criteria included pregnant women (1) who did not supply written informed consent; or (2) whose fetuses or babies had an abnormality; or (3) who had known severe medical, obstetric and/or psychiatric problems. Measurements The study used four measurement tools: Perceived Stress Scale (PSS), Social Support Rating Scale (SSRS), Edinburgh Postnatal Depression Scale (EPDS) and Zung Self-Rating Anxiety Scale (SAS). The Perceived Stress Scale measures the degree to which situations in one's life are appraised as stressful (Cohen, Kamarck, & Mermelstein, 1983). The version we used had 14 items that were rated on a 5-point Likert-type scale ranging from 0 (never) to 4 (very frequently). The PSS items were designed to tap the degree to which respondents found their lives unpredictable, uncontrollable and overloaded. These three factors have consistently been found to be central components of the experience of stress. Respondents were asked how often in the last month they had experienced specific feelings of stress. Reverse scoring was used for items describing negative experiences or responses. The total possible scores for the PSS ranged from 0 to 56, with higher scores representing higher levels of perceived stress. The internal consistency reliability (Mimura & Griffith, 2004), predictive and concurrent validity (Cohen et al., 1983) and factor structure (Ramirez & Hernandaz, 2007) were found to be satisfactory. A Chinese version of the PSS with satisfactory content validity and reliability (Chu, 2005) was adopted in this study. The Cronbach's α for the PSS was 0.81, suggesting good internal consistency. The Social Support Rating Scale by Xiao (1999) was used in this study because of the unique environmental and cultural conditions in China. The SSRS contains 10 items that measure three dimensions of social support: subjective support (SS) (4 items), objective support (OS) (3 items), and support availability (SA) (3 items). Subjective support reflects the perceived interpersonal network from friends, neighbours, colleagues and family members that an individual can count on. Objective support reflects the degree of actual support an individual received in the past with an emergency for financial, material or emotional support. Support availability refers to the pattern of behavior that an individual utilizes when seeking social support. The scores of each item of the SSRS are simply added up to generate a total support score ranging from 12 to 66, a subjective support score ranging from 8 to 32, an objective support score ranging from 1 to 22, and a support-seeking behavior score ranging from 3 to 12, respectively. Higher scores indicate stronger social support. The test–retest reliability of the SSRS exceeded 0.92 (Xiao, 1999). The SSRS has been applied on a wide range of Chinese populations because of its high reliability and validity (Gao, Chan, & Mao, 2009; Xie et al., 2009). The Cronbach's α was 0.71 in the present study, suggesting acceptable internal consistency. The Edinburgh Postnatal Depression Scale (Cox, Holden, & Sagovsky, 1987) was used to screen for antenatal depressive symptoms because it has already been validated for such use (Felice, Saliba, Grech, & Cox, 2006). The EPDS is a 10-item self-rating instrument, with each item scored using a 4-point scale. The minimum and maximum total scores are 0 and 30, respectively. This scale focuses on the cognitive and affective features of depression. A Chinese version tested on a mainland Chinese population demonstrated good reliability and validity (Lau, Wang, Yin, Chan, & Guo, 2010; Wang et al., 2009). The Cronbach's α for the EPDS was 0.77 in this study, suggesting acceptable internal consistency. The Zung Self-Rating Anxiety Scale (Zung, 1971) was used to quantify the level of anxiety. It is a 20-item scale measuring symptoms of anxiety, with some of the items reflecting positive perceptions and some, negative perceptions. The items are answered on a 4-point scale

307

ranging from 1 (none or a little of the time) to 4 (most or all of the time). Negatively-worded items are reverse-scored prior to the summation of the scores of the individual items. The total score is multiplied by 1.25 to reach a standardized score ranging from 25 to 100; a higher score reflects a higher level of anxiety and vice versa. A Chinese version of Zung's SAS has demonstrated adequate content validity (Zhang, Song, & Guo, 2009) and satisfactory reliability (Gao, Ip, & Sun, 2011). The Cronbach's α was 0.78 in the present study, suggesting acceptable internal consistency. Data Collection The target population was pregnant Chinese women living in Chengdu, China. All women who were attending the antenatal clinic in the study hospital during the data collection period from December 2012 to April 2013 were eligible for entry into the study if their obstetric records met the eligibility criteria. These women were first screened, and then approached individually by the investigator to confirm that those who were eligible satisfied the selection criteria before they were invited to participate in the study. All who were approached were given a full explanation of the study and informed of their right to refuse to participate. Data were collected from the women in the second trimester because physiological discomfort and stress levels would be comparatively lower than those experienced in other trimesters. Those who gave their written consent completed the self-report instruments in approximately 10 to 15 minutes while waiting for their routine antenatal check-up at the clinic. Data Analysis IBM SPSS Statistics 21.0 was used for data analysis. Reliability tests were carried out for the various scales. Descriptive analysis was used to describe the proportion of demographic and obstetric characteristics. Independent t tests were carried out to compare the PSS, EPDS, SAS and SSRS scores by demographic and obstetric characteristics. Pearson's correlation coefficient was performed for all the variables to determine associations. The results showed that SSRS, OS, SS and SA scores were highly correlated (r = 0.581 to 0.790, p b .001). Therefore, four separate statistical models were used to prevent problems of multicollinearity. To test the direct and moderating effects of social support in the relationship between perceived stress, and depressive and anxiety symptoms, multiple linear regression analyses were performed. The predictive variables, including demographic and obstetric variables (control variables), perceived stress and social support where the dependent variable was depressive symptoms (EPDS scores) or anxiety symptoms (SAS scores), an interaction term was added (Cohen & Cohen, 2003). Centered variables were used for perceived stress and the potential moderators were used to reduce multicollinearity resulting from the interaction term (Cohen & Cohen, 2003). The most widely-used data-analytic strategy involves examining the increase in explained variance (R 2) when the interaction term is added to the regression (Aiken & West, 1991). In addition, significant F values (p b .05) corresponding to the interaction of the two independent factors were taken as evidence of moderator effects (Aiken & West, 1991). To prevent multicollinearity among the variables, principal component analysis was performed with a collinearity diagnostics test (Stine, 1995). The variance inflation factor (VIF) was used to analyze the magnitude of multicollinearity, with VIF b 5 set as the acceptable level (O'Brien, 2007). RESULTS A total of 915 Chengdu Chinese women were invited to join the study, of whom 755 completed the questionnaires, yielding a response rate of 82.5%. The demographic characteristics of the non-respondents

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did not vary significantly from those of the respondents. Table 1 presents the demographic and socio-economic characteristics of the participants, and comparisons of PSS, EPDS, SAS and SSRS scores within groups. The majority (82.6%) of the participants were older than 25, had attained tertiary education (84.9%), and were married (98.4%). More than half (69.8%) of the women had full-time jobs with monthly incomes N RMB$4000 (63.0%). The fetuses of majority of them (85.4%) were at a gestational age of less than 24 weeks at the time of the study; less than half of the respondents (48.9%) were having their first pregnancy and 2.5% of them were impregnated via in vitro fertilization (IVF). More than half (67.3%) of the respondents had planned their pregnancies and 12.0% of them had had a history of miscarriage. Age, educational level, employment, weeks of gestation, total number of pregnancies and intention of pregnancy were found to have significantly different scores (p b .05) in the PSS scores by independent t tests. Educational levels, marital status, employment, weeks of gestation, total number of pregnancies and planning of pregnancy were found to have significant differences (p b .05) in the EPDS scores. Ages, educational level, weeks of gestation, total number of pregnancies and history of miscarriage were found to have significant differences (p b .05) in the SAS scores. Employment and planning of pregnancy were found to have significant differences (p b .05) in the SSRS scores. Table 2 shows the correlation matrix for all the variables in this study. The correlations between PSS and EPDS scores (r = .615), PSS and SAS scores (r = .409), and PSS and SSRS scores (r = − .275) were significant (p b .01). Roles of Social Support, Perceived Stress and Antenatal Depressive Symptoms Four multiple linear regression models revealed that women who perceived higher stress levels (β = .576 to .604, p b .001) were more likely to have antenatal depressive symptoms, as shown in Table 3. The OS scores (β = − .081, p b .007), SS scores (β = − .117, p b .001) and SSRS scores (β = − .127, p b .001) were negatively associated with EPDS scores after adjustment of demographic and

obstetric variables. These results can be interpreted to indicate that objective support, subjective support and total social support scores each may have a direct impact on antenatal depressive symptoms. As can be seen in Table 3, we found that the interactions between perceived stress and SS (β = − .058, p = .042) and SSRS (β = − .069, p = .015) were significant. These results can be interpreted to indicate that subjective support and total social support may act as buffers to alleviate the effects of perceived stress on antenatal depressive symptoms. The R 2 were .400 to .415; that is, 40.0 to 41.5% of the variation in the response variable (antenatal depressive symptoms) can be explained by the regressors (perceived stress, social support, demographic and obstetric variables). Therefore, the participants who have predominantly perceived higher levels of social support and who had perceived their interpersonal network to be more extensive were less likely to have antenatal depressive symptoms. Subjective Support, Perceived Stress and Antenatal Anxiety Symptoms Four multiple linear regression models revealed that women who perceived higher levels of stress (β = .402 to .410, p b .001) were more likely to have more severe antenatal anxiety symptoms, as shown in Table 4. None of the social support dimensions were negatively associated with SAS scores after adjustment of the demographic and obstetric variables. This result can be interpreted to indicate that social support has no direct effect on antenatal anxiety symptoms. As can be seen in Table 4, we found that the interaction between perceived stress and SS (β = − .090, p = .006) was significant. This result can be interpreted to indicate that subjective support acts as a buffer to alleviate the effects of the perceived stress on antenatal anxiety symptoms. The R 2 were .204 to .213, that is, 20.4 to 21.3% of the variation in the response variable (antenatal anxiety level) can be explained by the regressors (perceived stress, social support, and demographic and obstetric variables). Therefore, the participants who perceived their interpersonal network to be more extensive were likely to have less severe antenatal anxiety symptoms.

Table 1 Bivariate Comparisons of Perceived Stress, Antenatal Depressive Symptoms, Anxiety and Social Support Score by Demographic and Obstetric Characteristics Among Participant (N = 755).

Entire sample

Demographic and obstetric characteristics Age Educational level Marital status Employment Monthly incomeb Weeks of gestation Number of pregnancy History of miscarriage Intention of pregnancy IVF pregnancy NOTE.

≤25 N25 ≤Secondary NSecondary Others Married Others Full-time ≤RBM $4000 NRBM $4000 ≥24 weeks b24 weeks First NFirst Yes No Unplanned Planned Yes No

Perceived Stress Scale

Edinburgh Postnatal Depression Scale

n (%)

M (S.D.)

pa

M (S.D.)

131 (17.4) 624 (82.6) 114 (15.1) 641 (84.9) 12 (1.6) 743 (98.4) 228 (30.2) 527 (69.8) 279 (37.0) 476 (63.0) 110 (14.6) 645 (85.4) 369 (48.9) 386 (51.1) 96 (12.7) 659 (87.3) 247 (32.7) 508 (67.3) 19 (2.5) 736 (97.5)

24.78 22.16 25.48 22.10 26.00 22.56 23.80 22.10 23.15 22.30 20.92 22.90 21.90 23.30 22.68 22.61 23.66 22.10 23.68 22.59

b.001⁎⁎⁎

8.89 8.21 9.18 8.18 11.33 8.28 9.18 7.97 8.39 8.30 7.44 8.49 8.00 8.66 8.72 8.28 9.07 7.97 8.72 8.28

(6.17) (6.13) (5.60) (6.18) (6.45) (6.20) (6.58) (5.98) (6.29) (6.15) (6.31) (6.16) (6.19) (6.17) (6.13) (6.23) (6.26) (6.13) (6.24) (6.22)

b.001⁎⁎⁎ .057 .001⁎⁎ .070 .002⁎⁎ .002⁎⁎ .916 .001⁎⁎ .448

(3.87) (4.13) (4.03) (4.08) (5.66) (4.04) (4.51) (3.84) (4.22) (4.01) (4.12) (4.07) (4.04) (4.12) (4.01) (4.10) (3.87) (4.15) (4.01) (4.10)

pa .089 .016⁎ .010⁎ b.001⁎⁎⁎ .770 .013⁎ .027⁎ .324 .001⁎⁎ .324

Zung Self-rating Anxiety Scale

Social Support Rating Scale

M (SD)

pa

M (S.D.)

44.70 42.35 44.44 42.46 45.94 42.71 43.59 42.40 43.03 42.59 45.18 42.34 42.04 43.44 44.83 42.45 43.42 42.43 45.79 42.68

.004⁎⁎

40.95 41.47 40.34 41.57 37.92 41.44 39.82 42.06 42.23 41.47 42.11 41.26 41.57 41.20 40.73 41.48 40.25 41.93 39.53 41.43

(8.50) (8.42) (8.25) (8.49) (10.71) (8.44) (8.32) (8.53) (8.77) (8.31) (12.51) (7.52) (7.83) (9.01) (10.34) (8.14) (8.32) (8.54) (9.80) (8.43)

.020⁎ .190 .077 .493 .023⁎ .023⁎ .010⁎ .130 .114

(6.80) (6.04) (6.74) (6.05) (8.38) (6.12) (6.46) (5.93) (6.41) (6.03) (6.52) (6.11) (5.92) (6.41) (6.81) (6.08) (6.45) (5.97) (4.88) (6.20)

pa .383 .051 .050 b.001⁎⁎⁎ .593 .182 .411 .267 b.001⁎⁎⁎ .185

M (S.D.) = mean (standard deviation). Independent t test. b RMB$4000 = approximately US$700. RBM$4000 was considered as cut-off because this represents the median monthly domestic household income in Mainland China. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001. a

Table 2 Mean, Standard Deviations, Range and Correlation Matrix of Variables Among Participants (N = 755).

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 NOTE.

Age Educational level Marital status Employment status Monthly income Weeks of gestation Number of pregnancy History of miscarriage Intention of pregnancy IVF pregnancy PSS EPDS SAS SSRS OS SS SU

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

1.00 .256⁎⁎ −.002 .179⁎⁎ .149⁎⁎ .009 .035 −.049 .173⁎⁎ −.007 .160 .062 .105⁎⁎ −.032 −.053 .023 −.068

1.00 .153⁎⁎ .311⁎⁎ .168⁎⁎ .025 −.176 .072 .163⁎⁎ .050 .195⁎⁎ .088⁎ .084⁎ −.071 −.194⁎ .109⁎⁎ −.139⁎⁎

1.00 .101⁎⁎ .078⁎ −.022 −.061 .047 .092⁎ −.020 .069 .093⁎ .048 −.071⁎ −.068 −.050 −.026

1.00 .148⁎⁎ −.010 −.135⁎⁎ .069 .138⁎⁎ .060 .125⁎⁎ .135⁎⁎ .064 −.167⁎⁎ −.180 −.042 −.181⁎⁎

1.00 −.044 .047 .021 .039 −.035 .066 .011 .025 −.019 −.048 .010 −.006

1.00 −.021 .102⁎⁎ .008 .053 −.113⁎⁎ −.091⁎ .118 .049 .036 .047 .008

1.00 −.365⁎ −.061 −.056 −.113⁎⁎ −.081⁎ −.083⁎ .030 .047 −.041 .108⁎⁎

1.00 −.020 .066 .004 .036 .093⁎ −.040 −.066 .002 −.030

1.00 .230 .118⁎⁎ .126⁎⁎ .055 −.128⁎⁎ −.140⁎⁎ −.045 −.110⁎⁎

1.00 .028 .053 .058 −.048 −.034 −.036 −.033

1.00 .615⁎⁎ .409⁎⁎ −.275⁎⁎ −.198⁎⁎ −.198⁎⁎ −.197⁎⁎

1.00 .483⁎⁎ −.308⁎⁎ −.210⁎⁎ −.251⁎⁎ −.181⁎⁎

1.00 −.169⁎⁎ −142⁎⁎ −.119⁎⁎ −.093⁎

1.00 .717⁎⁎ .790⁎⁎ .581⁎⁎

1.00 .233⁎⁎ .283⁎⁎

1.00 .248⁎⁎

1.00

PSS = Perceived Stress Scale; EPDS = Edinburgh Postnatal Depression Scale; SAS = Zung Self-rating Anxiety Scale; SSRS = Social Support Rating Scale (SSRS); OS = objective support; SS = subjective support; SU = support utility. M (S.D.) = mean (standard deviation). ⁎ Correlation is significant at the 0.05 level (2-tailed). ⁎⁎ Correlation is significant at the 0.01 level (2-tailed).

Y. Lau et al. / Archives of Psychiatric Nursing 28 (2014) 305–313

Demographic and obstetric characteristics

309

2 NOTE. B = unstandardized coefficient; SE = standard error; t = t value; β = standardized coefficient; R = explained variance; VIF = variance inflation factor. Results shown are from four multiple linear regression models after adjusting for demographic and obstetric variables. ⁎ p b .05. ⁎⁎ p b .01. ⁎⁎⁎ p b .001.

– – – 0.015⁎ – – – −2.441 – – – −.069 – – – – – – −.275 .113 .415 1.019–1.223 – – 0.066 – – – −.053 – 0.105 – – – −1.621 – – –

– – −.226 .111 – – – – .412 1.015–1.286

– −.058 – –

– −2.036 – –

– 0.042⁎ – –

– – – – −.220 .119 – – .400 1.015–1.257

– – −1.838 –

b.0001⁎⁎⁎ – – – b.0001⁎⁎⁎ 18.986 – – – −4.246 .576 – – – −.127 .379 – – – −.084 .604 – – −.053 – b.0001⁎⁎⁎ 0.007⁎⁎ – – –

Perceived stress and social support Perceived Stress Scale (PSS) .394 .020 .598 OS −.109 .040 −.081 SS – – – SU – – – SSRS – – – Interaction effects of perceived stress and social support PSS × OS −.178 .110 −.046 PSS × SS – – – PSS × SU – – – PSS × SSRS – – – R2 .403 VIF 1.033–1.270

19.937 −2.723 – – –

.384 – −.129 – –

.020 – .032 – –

.584 – −.117 – –

19.362 – −3.981 – –

b.0001⁎⁎⁎ – b.0001⁎⁎⁎ – –

.398 – – −.120 –

.020 – – .067 –

20.093 – – −1.781 –

b.0001 – – 0.075 –

.020 – – – .020

Sig. t β SE B Sig. t

Support utility (SU)

β t β t β SE B

Objective support (OS)

Sig.

B

SE

Subjective support (SS)

Sig.

B

SE

Social Support Rating Scale (SSRS) total score

Y. Lau et al. / Archives of Psychiatric Nursing 28 (2014) 305–313

Table 3 Multiple Linear Regression Analysis of Social Support and Interaction Effect of Social Support and Perceived Stress Associated With Antenatal Depressive Symptoms After Adjustment (N = 755).

310

DISCUSSION Consistent with previous studies (Razurel et al., 2013; Roos et al., 2013), the results of this study indicate that women who perceived stress were more likely to develop depressive and anxiety symptoms. Comorbid depressive and anxiety symptoms are probably the most vulnerable conditions leading to an excessive stimulation of the hypothalamic–pituitary adrenal axis and an excessive secretion of stress hormones (Cardwell, 2013). It has been speculated that stress may result in higher somatic arousal and may threaten women's coping resources and adaptive capacity (Schetter, 2010). This, in turn, may be perceived as an ominous indication of vulnerability toward failure and lead to impairment of subsequent well-being, as manifested in depressive and anxiety symptoms (Ali et al., 2012). Pregnancy-related stress, however, differs from general stress in that it relates specifically to events or occurrences experienced by women who are pregnant, including physical and physiological changes, changes in interpersonal relationships, and concerns about labor and birth, health of the unborn infant and parenting (Chang, Kenney, & Chao, 2010). The findings suggest that perceived stress can have a detrimental effect on depressive and anxiety symptoms among pregnant Chengdu women. Direct Effects Social Support on Antenatal Depressive Symptoms The results of this study confirm that subjective, objective and total social support each has a direct effect on depressive symptoms. A possible explanation for the direct effects of social support may be related to psychosocial mechanisms (Thoits, 2011) and neuroendocrine or immune system functioning (Cardwell, 2013) according to the PNI framework (McCain et al., 2005). When women perceive that social support is available to them, they are more likely to be in a more positive affective state (Wills & Fegan, 2001). Social support may reduce stress by creating better self-rated health (Lamarca, Leal, Sheiham, & Vettore, 2013), better health-related quality of life (Emmanuel, St John, & Sun, 2012), positive self-efficacy, self-esteem or self-worth (Umaña-Taylor, Guimond, Updegraff, & Jahromi, 2013), and a sense of well-being, personal control and mastery (Thoits, 2011) —all of which are related to overall well-being and thus have the potential of reducing the likelihood of experiencing depressive symptoms. On the other hand, the lack of social support may have an effect on depressive symptoms arising from negative beliefs such as non-acceptance by others, low self-worth and reduced connectedness with others (Ibarra-Rovillard & Kuiper, 2011). A second explanation for the direct effects of social support on depressive symptoms relates to mechanisms through which poorer social support could increase one's vulnerability to psychological problems involving hypothalamic–pituitary adrenal axis dysregulation (Hostinar & Gunnar, 2013). Conversely, better social support may diminish or block acute responses to stressors by reducing stress reactivity (Hostinar & Gunnar, 2013). Furthermore, in light of evidence showing that the link between social support and depression is bidirectional, the relationship should also consider the effects of the small size of depressed women's social support networks on their satisfaction with support received from their social networks (Nylen, O'Hara, & Engeldinger, 2013). The depressed women who were associated with stress did not appear to experience alleviation of symptoms through perception of social support because of their isolating behaviors (Sirin et al., 2013). Unexpectedly, our study shows that the direct effect of social support is not found on anxiety symptoms, which is inconsistent with previous studies (Aktan, 2012; Roos et al., 2013). This finding may relate to the nature of our study population and the magnitude of unexplained variance (78.7 to 79.6%). Because the mean score of SAS in our study was 34.21, which can be interpreted that our sample had low anxiety levels, the direct effect of social support on anxiety

0.991 – – – .011 – – –

2 NOTE. B = unstandardized coefficient; SE = standard error; t = t value; β = standardized coefficient; R = explained variance; VIF = variance inflation factor. Results shown are from four multiple linear regression models after adjusting for demographic and obstetric variables. ⁎ p b .05. ** p b .01. ⁎⁎⁎ p b .001.

– – – 0.111 – –– – −1.598 – – – −.053 – – 0.962 – – −.090 – – – – −.732 .267 – – – – .213 1.034–1.286

– −2.748 – –

– 0.006⁎ – –

– – – – .013 .285 – – .204 1.015–1.257

– – .002 –

– – .047 –

– – – – – – −.434 272 .210 1.033–1.253

b.0001⁎⁎⁎ – – – 0.100 11.401 – – – −1.646 .402 – – – −.057 .548 – – – −.078 b.0001⁎⁎⁎ – – 0.829 – .407 – −.037 – – b.0001⁎⁎⁎ 0.056 – – – 11.871 −1.917 – – –

.555 – −.084 – –

.048 – .077 – –

11.671 – −1.088 –– –

b.0001⁎⁎⁎ – 0.277 – –

.572 – – −.035 ––

.047 – – .160 –

.418 – – −.007 –

12.107 – – −.216 –

.048 – – – .048

Sig. t β SE B Sig. t β SE B Sig. t β SE B Sig. t β SE B

Perceived stress and social support Perceived Stress Scale (PSS) .560 .047 .410 OS −.183 .095 −.066 SS – – – SU – – – SSRS – – – Interaction effects of perceived stress and social support PSS × OS .003 .263 .000 PSS × SS – – – PSS × SU – – – PSS × SSRS – – – R2 .208 VIF 1.033–1.270

Support utility (SU) Subjective support (SS) Objective support (OS)

Table 4 Multiple Linear Regression Analysis of Social Support and Interaction Effect of Social Support and Perceived Stress Associated With Antenatal Anxiety After Adjustment (N = 755).

Social Support Rating Scale (SSRS) total score

Y. Lau et al. / Archives of Psychiatric Nursing 28 (2014) 305–313

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symptoms might be less obvious in this study. For this data analysis, two multiple linear regression models of anxiety symptoms on predictor variables (that is, perceived stress, social support and demographic and obstetric variables) accounted for only 20.4 to 21.3% of the variance; thus, future studies should explore additional variables in explaining antenatal anxiety symptoms. However, it is unclear why the direct effect of social support is only found on depressive pregnant women but not on anxious pregnant women in this study, and thus further study is warranted. Although the functions of support can be distinguished conceptually, in natural settings they are not usually independent. This intercorrelation among the three social support dimensions is supported by a significant correlation (R2 = .233 to .283, p b .01). For example, it is likely that people who have higher levels of subjective social support also have a greater chance of receiving objective support. Social support would enhance the individual's resourcefulness, and conversely a resourceful person would seek assistance from others when they are unable to function independently under stressful situations (Ngai & Chan, 2012). These possibilities should be explored in future research. Moderating Effects of Subjective Social Support on Antenatal Depressive and Anxiety Symptoms This study has helped to elucidate the moderating effects of subjective social support in alleviating depressive and anxiety symptoms during pregnancy among a population of pregnant Chengdu women. Subjective social support has been more consistently related to health outcomes than objective support and support availability, which echoes the results of studies conducted in Western countries (Gottlieb & Bergen, 2010; Gulacti, 2010). Subjective support may be more strongly linked to its early familial influences, stability and association with other positive profiles (Uchino, 2009). In contrast to subjective support, objective support and social availability are situational factors that arise in response to stressful circumstances (Uchino, 2009). Subjective support refers to anticipating help in times of need, whereas objective support and support availability refer to recalling help received within a given period in the past (Ibarra-Rovillard & Kuiper, 2011). Subjective support gives women better subjective well-being (Gulacti, 2010) and a person with a strong sense of psychological support fare better in the face of adversity (Gottlieb & Bergen, 2010). Paradoxically, a strong sense of support seems to give women the confidence to cope without needing to marshal their network resources. As a result, higher levels of perceived subjective support have a more positive psychological impact on pregnant women than objective support or support availability. In line with the PNI framework (McCain et al., 2005), the results of this study confirm that subjective social support has an interactive effect on ameliorating the depressive and anxiety symptoms of pregnant women who are experiencing stress. Subjective social support may act as an intrapersonal resource that helps women to cope and adapt to stressful situations (Cohen & Wills, 1985). One possibility of this observation may be related to mediation effects of religion and spirituality influences on depressive and anxiety symptoms (Dew et al., 2010; Rasic, Robinson, Bolton, Bienvenu, & Sareen, 2011). The Chinese women who participated in this study might have tapped on their self-reliant personality (Xia, Ding, Hollon, & Wan, 2013) as a resource or acquired skills that enhanced their resourcefulness (Ngai & Chan, 2012) that, in turn, could have affected the quality of practical problem-solving and helped them construct a positive schema about themselves, others and the world. This, in turn, reduced the negative impact that perceived stress has on their mental well-being (Ngai & Chan, 2012; Xia, Huang, Wan, & Yang, 2011). Subjective support has an effect on women's adjustment and appraisal of the potential or existing stressor (Abadi, Ghazinour, Nojomi, & Richter, 2013) through positive coping assistance strategies

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(Thoits, 2011). Coping assistance strategies include helping the depressive and/or anxious woman to see the situation in a different way, suggesting ways to solve problems, encouraging her to vent her negative feelings, and providing distraction from the stress. These strategies may also bolster the depressive and/or anxious woman's sense of personal control, counteracting the stressors' psychological impacts indirectly (Thoits, 2011). Subjective social support is highly valued among pregnant women as it has a cushioning effect against the challenges that come with the necessary adjustments that occur during pregnancy (Emmanuel et al., 2012). Pregnant women would carry a positive and reasonable attitude towards stressful events and view the events as a challenge (Liu et al., 2011), so that the impact of stress on depressive and/or anxiety symptoms is lessened. Limitations The study has a number of limitations. First, the study design was cross-sectional, which precludes drawing definitive conclusions regarding the direction of relationships between variables. Besides, social support may change over time during pregnancy (Smith & Howard, 2008). Therefore, a longitudinal study is needed to explore the causal relationship between variables in the future. Second, the sample was a convenience sample comprising pregnant women in one hospital and therefore the results of this study may not be generalized nationwide to the population in China or to elsewhere. Third, all the four questionnaires used for this study were based on self-reports and therefore prone to the effects of social desirability. Fourth, it is not feasible to separate two concepts of depression and anxiety because they are interrelated (Friedman, Clark, & Greshon, 1992), thus it is difficult to differentiate two psychological outcomes among pregnant women. Finally, although this study examined the relationship between the roles of social support, perceived stress, antenatal depressive or anxiety symptoms, it did not address several other significant factors, such as loneliness, domestic violence, and unintended pregnancy. Implications Prenatal care provides a window of opportunity to assess and implement care for women experiencing stress and depressive and/or anxiety symptoms. Unfortunately, screening for stress levels, and for depressive and/or anxiety symptoms has not been widely implemented as a part of routine prenatal care in Chengdu, China. It may thus be useful to incorporate screening tools for stress, and for depressive and/or anxiety symptoms into current questionnaires that screen patients' clinical history, so that those who are experiencing undue stress and high levels of depressive and/or anxiety symptoms may be identified and referred for intervention early. The data from our study suggest that subjective support can alleviate perceived stress and in turn, protect pregnant women from depressive and/or anxiety symptoms. Building upon prior social network strategies, health-care professionals could design programs to help women assess which relationships in their social network should be enhanced. Such interventions could also encourage women to develop new social networks, as a study (Nguyen et al., 2012) has suggested that new ties are often forged in response to major transitions or stressors during pregnancy. Thus, health-care professionals should consider developing interventions that bolster pregnant women's psychosocial support (Thalen-Lindstrom, Larsson, Glimelius, & Johansson, 2013), mindfulness-based interventions (Perez-Blasco, Viguer, & Rodrigo, 2013) or community-based outreach (Fleming, Tu, & Black, 2012). Such interventions should tailor the type and amount of support to the individual needs of pregnant women. In addition, efforts must be made to present information in culturally-appropriate formats so as not to overwhelm women who may be already struggling to cope with their pregnancy.

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