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1.  Grief and Women: Stillbirth in the Social Context of India 
INTRODUCTION
Few in Western society would argue the potentially devastating impact of stillbirth related grief; but in many developing countries where stillbirth remains the highest in the world, perinatal grief is barely recognized as an issue. The purpose of this study was to explore how poor, rural central Indian women perceive and cope with stillbirths.
METHODS
Seventeen key informant interviews and two focus groups (N = 33) with local health care providers, family members, and women who experienced stillbirth were conducted over a 1-month period in 2011 and then systematically coded for emerging themes using grounded theory methods to explore how women experienced stillbirth.
RESULTS
Although usually never talked about and not recognized as an issue, perinatal grief emerged as a significant shared experience by all. The perceptions of stillbirth-related grief emerged in three major themes and bear evidence of gender and power issues and indicate that local social norms negatively factor heavily into their perinatal grief experiences.
DISCUSSION
The findings in this richly textured study add to the limited literature regarding rural, central Indian women's experiences with stillbirth and factors influencing their resulting perinatal grief. In light of the void of recognition of this phenomenon in Indian society, a better understanding of the context in which poor Indian women experience perinatal grief will be a first step toward developing much needed culturally rooted interventions to positively impact the women's abilities to better cope with stillbirth in the context of their realities.
doi:10.1891/2156-5287.2.3.187
PMCID: PMC4652937  PMID: 26594592
perinatal grief; gender; power (psychology); social conformity; India
2.  The Association of TV Watching to Sleep Problems in a Church-going Population 
Family & community health  2014;37(4):279-287.
Sensory stimuli/inactivity may affect sleep. Sleep problems are associated with multiple health problems. We assessed TV habits in the Adventist Health Study-2 at baseline and sleep problems in the Biopsychosocial Religion and Health Study 1–4 years later. After exclusions, 3,914 subjects split equally into TV watchers <2 hours/day or ≥2 hours/day. Watching TV ≥2 hours/day predicted problems falling asleep, middle of the night awakening and waking early with inability to sleep again in multiple logistic regression. Excess TV watching disturbed sleep induction and quality, though the relationship may be bidirectional. TV habits should be considered in individuals with sleep problems.
doi:10.1097/FCH.0000000000000038
PMCID: PMC4607020  PMID: 25167068
Church-goers; lifestyle; sleep; TV watching
3.  Predicting Malawian Women’s Intention to Adhere to Antiretroviral Therapy 
Background
With the increase in scaling up of antiretroviral therapy (ART), knowledge of the need for adherence to ART is pivotal for successful treatment outcomes.
Design and Methods
A cross-sectional study was carried out between October and December 2013. We administered theory of planned behaviour (TPB) and adherence questionnaires to 358 women aged 18-49 years, from a rural and urban ART-clinics in southern Malawi. Hierarchical linear regression models were used to predict intentions to adhere to ART.
Results
Regression models show that attitude (β=0.47), subjective norm (β=0.31) and perceived behavioural control (β=0.12) explain 55% of the variance in intentions to adhere to ART. The relationship between both food insecurity and perceived side effects with intentions to adhere to ART is mediated by attitude, subjective norm, and perceived behavioural control. Household (r=0.20) and individual (r=0.21) food insecurity were positively and significantly correlated with perceived behavioural control. Household food insecurity had a negative correlation with perceived side effects (r=-0.11). Perceived side effects were positively correlated with attitude (r=0.25). There was no statistically significant relationship between intentions to adhere to ART in the future and one month self-report of past month adherence. These interactions suggest that attitude predicted adherence only when food insecurity is high or perception of side effects is strong.
Conclusions
This study shows that modification might be needed when using TPB constructs in resource constraint environments.
Significance for public healthThe knowledge of the rates of adherence to antiretroviral therapy (ART) could be used to evaluate planning and project, which could lead to better outcomes predicted by treatment efficacy data. In addition, knowledge of adherence behaviour could help the development of interventions focusing on collaboration between healthcare providers and Malawian government to provide food support for patients on ART. The interventions could also focus on providing better counselling support to improve beliefs regarding control over taking the medication and perceived versus real side effects. It is relevant for public health professors to understand factors influencing women’s ART adherence, in order to create interventions that are appropriate for increasing ART adherence, which may lead to improved outcomes among women with HIV living in endemic regions with limited treatment access.
doi:10.4081/jphr.2015.533
PMCID: PMC4568423  PMID: 26425494
Antiretroviral therapy; adherence; theory of planned behaviour; women; food insecurity
4.  Bidirectional longitudinal study of type 2 diabetes and depression symptoms in black and white church going adults 
Background
There is a need to longitudinally examine depression and DM2 relationship in a population that values positive health behaviors. The aim of this study was to prospectively investigate the bidirectional relationship between depression and DM2.
Methods
A cohort sample of 4,746 Black (28.4%) and White (71.6%) Seventh-day Adventist adults who participated in the Biopsychosocial Religion and Health Study (BRHS) completed a short form of the Center for Epidemiologic Studies Depression Scale (CES-D) 11 along with self-report of lifetime physician diagnosis of type 2 diabetes (DM2) and treatment of DM2 and/or depression in the last 12 months in 2006–7 and 2010–11. Hierarchical logistic regression analyses were completed to predict risk for future disease while controlling for demographic and health related variables.
Results
While there were no direct effects of depression on later DM2, there was an indirect effect mediated by BMI (effect = 0.13; 95% CIs [0.08, 0.20]) even after controlling for demographic variables as covariates using Hayes’ PROCESS macro mediation analysis. Similarly, there was also only an indirect effect of DM2 on later depression mediated by BMI (effect = 0.13; 95% CIs [0.05, 0.22]) after controlling for demographic variables.
Conclusions
The results highlight BMI as a risk factor for both DM2 and depression. The negative consequences of having higher BMI in conjunction at baseline with another disease can increase the risk for other chronic disease even in a span of 2.04 – 5.74 years, the length of study interval.
doi:10.1186/s40200-015-0150-5
PMCID: PMC4404000  PMID: 25897418
Type 2 diabetes; Depression; Bidirectional; Black; Adventist
5.  Religious Engagement in a Risky Family Model Predicting Health in Older Black and White Seventh-day Adventists 
In a structural equation model, associations among latent variables – Child Poverty, Risky Family exposure, Religious Engagement, Negative Social Interactions, Negative Emotionality, and Perceived Physical Health – were evaluated in 6,753 Black and White adults aged 35–106 years (M = 60.5, SD = 13.0). All participants were members of the Seventh-day Adventist church surveyed in the Biopsychosocial Religion and Health Study (BRHS). Child Poverty was positively associated with both Risky Family exposure (conflict, neglect, abuse) and Religious Engagement (intrinsic religiosity, religious coping, religiousness). Risky Family was negatively associated with Religious Engagement and positively associated with both Negative Social Interactions (intrusive, failed to help, insensitive, rejecting) and Negative Emotionality (depression, negative affect, neuroticism). Religious Engagement was negatively associated with Negative Emotionality and Negative Social Interactions at a given level of risky family. Negative Social Interactions was positively associated with Negative Emotionality, which had a direct, negative effect on Perceived Physical Health. All constructs had indirect effects on Perceived Physical Health through Negative Emotionality. The effects of a risky family environment appear to be enduring, negatively affecting one’s adult religious life, emotionality, social interactions, and perceived health. Religious engagement, however, may counteract the damaging effects of early life stress.
doi:10.1037/a0027553
PMCID: PMC3613156  PMID: 23560134
religious engagement; risky family; emotionality; physical health
6.  Intake of Mediterranean foods associated with positive affect and low negative affect 
Journal of psychosomatic research  2012;74(2):142-148.
Objective
To examine associations between consumption of foods typical of Mediterranean versus Western diets with positive and negative affect. Nutrients influence mental states yet few studies have examined whether foods protective or deleterious for cardiovascular disease affect mood.
Methods
Participants were 9255 Adventist church attendees in North America who completed a validated food frequency questionnaire in 2002–6. Scores for affect were obtained from the Positive and Negative Affect Schedule questionnaire in 2006–7. Multiple linear regression models controlled for age, gender, ethnicity, BMI, education, sleep, sleep squared (to account for high or low amounts), exercise, total caloric intake, alcohol and time between the questionnaires.
Results
Intake of vegetables (β=0.124 [95% CI 0.101, 0.147]), fruit (β=0.066 [95% CI 0.046, 0.085]), olive oil (β=0.070 [95% CI 0.029, 0.111]), nuts (β=0.054 [95% CI 0.026, 0.082]), and legumes (β=0.055 [95% CI 0.032, 0.077]) were associated with positive affect while sweets/desserts (β=−0.066 [95% CI −0.086, −0.046]), soda (β=−0.025 [95% CI −0.037, −0.013]) and fast food frequency (β=−0.046 [95% CI −0.062, −0.030]) were inversely associated with positive affect. Intake of sweets/desserts (β=0.058 [95% CI 0.037, 0.078]) and fast food frequency (β=0.052 [95% CI 0.036, 0.068]) were associated with negative affect while intake of vegetables (β=−0.076 [95% CI −0.099, −0.052]), fruit (β=−0.033 [95% CI −0.053, −0.014]) and nuts (β=−0.088 [95% CI −0.116, −0.060]) were inversely associated with negative affect. Gender interacted with red meat intake (P<.001) and fast food frequency (P<.001) such that these foods were associated with negative affect in females only.
Conclusions
Foods typical of Mediterranean diets were associated with positive affect as well as lower negative affect while Western foods were associated with low positive affect in general and negative affect in women.
doi:10.1016/j.jpsychores.2012.11.002
PMCID: PMC3790574  PMID: 23332529
Affect; Dietary behaviors; Mediterranean; Mental health; Western
7.  Determinants of Inflammatory Markers in a Bi-ethnic Population 
Ethnicity & disease  2011;21(2):142-149.
Background
Inflammation is a common pathophysiological pathway for a number of chronic diseases, and is strongly influenced by sociodemographic factors and lifestyle. Less is known about factors that may influence the inflammatory response in individuals of distinct ethnic backgrounds. Therefore, this study examined the relationship between ethnicity and blood levels of inflammatory markers in a sample of non-smoking church-goers.
Methods
In a cross-sectional investigation, 508 men and women (>35 years old, 62% White, 38% Black) participated in the Biopsy-chosocial Religion and Health substudy of the Adventist Health Study 2. The contribution of socioeconomic status (education level and difficulty meeting expenses for basic needs) and health covariates (exercise, vegetarian or other type of diet, body mass index, and presence of inflammatory conditions) toward serum levels of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) was assessed with linear regression models. Levels of interleukin-10 (IL-10), an anti-inflammatory marker, were also assessed.
Results
Blacks showed higher levels of CRP and IL-6 than Whites. Controlling for socio-demographic and health variables attenuated the ethnic difference in CRP while IL-6 levels remained higher in Blacks than in Whites (β=.118; 95% confidence interval=.014–.206; P=.025). Ethnic differences in IL-10 and TNF-α were not found. Vegetarian diet was associated with lower CRP levels while exercise frequency was associated with higher IL-10 levels.
Conclusion
Higher susceptibility of Blacks to inflammatory diseases may reflect higher IL-6, which could be important in assessing health disparities among Blacks and Whites. Vegetarian diet and exercise may counteract effects of disparities.
PMCID: PMC3427005  PMID: 21749016
Inflammatory Markers; Ethnicity; Health Behavior; Adventists
8.  Clarifying and Measuring Filial Concepts across Five Cultural Groups 
Research in nursing & health  2011;34(4):310-326.
Literature on responsibility of adult children for aging parents reflects lack of conceptual clarity. We examined filial concepts across five cultural groups: African-, Asian-, Euro-, Latino-, and Native Americans. Data were randomly divided for scale development (n = 285) and cross-validation (n = 284). Exploratory factor analysis on 59 items identified three filial concepts: Responsibility, Respect, and Care. Confirmatory factor analysis on a 12-item final scale showed data fit the three-factor model better than the single factor solution despite substantial correlations between the factors (.82, .82 for Care with Responsibility and Respect, and .74 for Responsibility with Respect). The scale can be used in cross-cultural research to test hypotheses that predict associations among filial values, filial caregiving, and caregiver health outcomes.
doi:10.1002/nur.20444
PMCID: PMC3155420  PMID: 21618557
culture; filial attitudes; filial values; intergenerational responsibility; reciprocity; caregiver health outcomes

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