Research shows that 20% to 25% of women will experience depression during their life and that depression is common among women of child bearing age.1–6 Depression is one of the most common reasons for a nonobstetric hospital stay among women 18 to 44 years old.7 Gender differences in rates of depression are generally not observed until after puberty and appear to decrease after menopause; hormones, along with stress and other predisposing biologic, social, and psychosocial factors, may play a role in experiences with depression.1,2,5–8 Women experience higher prevalence of both mental distress (eg, depression, mood disorders) and physical distress (eg, activity limitation) than men, and the prevalence of these is even higher for women of reproductive age.8–13
Socioeconomic factors such as marital status, education, and family history of mood disorders are linked with health-related behaviors and health outcomes.14,15 Studies have shown that poor mental and physical health is related to participation in high-risk behaviors of cigarette smoking and alcohol and illicit drug use and that these factors in turn are associated with increased mortality and morbidity.3,4,16–23 Furthermore, mental and physical health problems during pregnancy are linked to poor attendance at antenatal clinics, continuation of high-risk behaviors (eg, cigarette smoking), poor social functioning, preeclampsia, low birth weight, preterm births, and problems with social and emotional development among children.24–27 Two recently published studies focused on the high prevalence of depression among pregnant women and the lack of attention to systematic screenings and counseling of women during this critical period.28,29 In fact, some researchers and practitioners have suggested integrating behavioral healthcare with routine practice of obstetrics and gynecology, because such practitioners are often the primary care providers for reproductive-age women.30 The purpose of this study was to examine the distribution of mental and physical health distress measured by the Health Related Quality of Life indicators and the association between these indicators and cigarette and alcohol consumption among reproductive-age women. We selected women of reproductive age for several reasons, including higher rates of mental and physical distress, life-stage, and prevention opportunities available to them at this time. We stratified our analysis by pregnancy status because many women change their own behaviors while others are advised to avoid high-risk behaviors.
MATERIALS AND METHODS
We analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for 1998, 2000, and 2001. Behavioral Risk Factor Surveillance System data from 1999 were not included because the Health Related Quality of Life module was not part of the 1999 Behavioral Risk Factor Surveillance System survey. The Behavioral Risk Factor Surveillance System is an ongoing, state-based, random-digit-dialed telephone survey of the noninstitutionalized US population 18 years of age or older. It is used to monitor health-related behaviors and characteristics in all 50 states, the District of Columbia, and the 3 US territories of Puerto Rico, US Virgin Islands, and Guam. The Behavioral Risk Factor Surveillance System survey included a core set of 4 Health Related Quality of Life measures, collected by all states, and an optional rotating module, selected by certain states, with additional Health Related Quality of Life questions that were administered by 13 states in 1998, 23 states in 2000, and 13 states in 2001. Response rates varied by state, the median response rates were 59.1% for 1998; 48.9% for 2000; and 51.1% for 2001. Of the 156,428 female Behavioral Risk Factor Surveillance System participants of reproductive age, 147,532 (94%) had information on pregnancy status available. The percentage excluded for missing data ranged from less than 0.2% for women’s age to 11% for income. Behavioral Risk Factor Surveillance System data quality is optimal when compared with other national surveys, data are shown to be reliable and valid, and additional information is available online at http://www.cdc.gov/ Behavioral Risk Factor Surveillance System.31 This study was approved by the Institutional Review Board of the Centers for Disease Control and Prevention.
We used both core and module Health Related Quality of Life indicators to assess the nature and extent of self-reported physical and mental distress among women of reproductive age (Box). We used general self-reported health status (n = 147,373), recent physical health (n = 146,272), recent mental health (n = 145,838), and recent activity limitation due to poor physical or mental health (n = 88,101). Health Related Quality of Life indicators for recent depression (n = 40,638), stress and anxiety (n = 40,502), and lack of rest (n = 40,725) were assessed from the optional modules. These Health Related Quality of Life measures have been validated among several populations in the United States and other countries.32 Measures in this study were dichotomized by using 14 or more days as the cutoff value for determining the chronic presence of mental and physical distress.9–13
Questions Used to Assess the Health Related Quality of Life Measures, Behavioral Risk Factor Surveillance System
Health Related Quality of Life Questions From the Core Module
General Health Status: “In general, would you say your health is excellent, very good, good, fair, or poor?”
Physical Health: “Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?”
Mental Health: “Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”
Activity Limitation: “During the past 30 days, for about how many days did poor physical or mental health keep you from doing usual activities, such as self care, work, or recreation?”
Health Related Quality of Life Questions From the Optional Module*
Depression: “During the past 30 days, for about how many days have you felt sad, blue, or depressed?”
Stress and Anxiety: “During the past 30 days, for about how many days have you felt worried, tense, or anxious?”
Lack of Rest: “During the past 30 days, for about how many days you felt that you did not get enough rest or sleep?”
*A selected set of states used the optional module with these questions.
We considered a number of demographic variables in the analysis including women’s age, race, education, marital status, whether they had any children, income, and health insurance coverage. The 2 health-risk behaviors examined were cigarette smoking and alcohol use. These behaviors were examined because pregnant women are advised to refrain from smoking and using any alcohol and because these have been linked to mental distress and adverse pregnancy outcomes. Women were considered to have a history of cigarette smoking if they reported smoking at least 100 cigarettes in their lifetime and to be current smokers if they reported smoking “every day” or “some days.” Alcohol use was defined as having had at least one drink of an alcoholic beverage during the past month. Binge drinking was defined as having consumed 5 or more drinks on one occasion in the previous month. We used software for survey data analysis (SUDAAN, Research Triangle Institute, Research Triangle Park, NC) to account for the complex sample design and to generate prevalence estimates and standard errors and to perform multivariate analyses.
The overall demographic characteristics of the population indicate that more than 50% of the women were between 30 to 44 years of age; 67.3% of the population studied was white, 11.4% black, 15.8% Hispanic, and 5.5% were categorized as other. The majority were married, had children, had incomes of $25,000 or above, and reported having health insurance coverage (Table 1). Overall, 4.6% (6,208) of the women were pregnant at the time of the interview. The demographic profile of pregnant women was quite similar to that of nonpregnant women on race, education level, and income. However, a higher proportion of pregnant women were younger, married, and reported having health insurance (Table 1).
The majority of women reported that their general health was excellent (25.8%; 95% confidence interval [CI] 24.4–26.2) or very good (36.4%; 95% CI 36.0–36.8); more than a quarter reported that their health was good (28.2%; 95% CI 27.6–28.4), and 9.3% (95% CI 9.0–9.6) reported that their health was fair or poor (Table 2). Overall, 6.7% (95% CI 6.5–6.9) reported frequent physical distress, 12.3% (95% CI 12.0–12.6) reported frequent mental distress, and 7.1% (95% CI 6.7–7.4) reported frequent activity limitation due to poor mental or physical health (Table 2). Approximately 9.9% (95% CI 9.4–10.4) reported that they frequently felt sad, blue, or depressed; 18.4% (95% CI 17.8–19.1) reported feeling frequently worried, tense, or anxious; and 34.3% (95% CI 33.5–35.1) reported that they frequently did not get enough rest or sleep. Nonpregnant women had a higher prevalence of cigarette smoking (25.1%; 95% CI 24.7–25.5) than pregnant women (12.3%; 95% CI 11.0–13.6), as well as higher rates of alcohol use in the past month (54.7% compared with 11.6%) and binge drinking (19.8% compared with 3.8%).
Among nonpregnant women, those who reported fair or poor health were more likely (odds ratio [OR] 1.6; 95% CI 1.4–1.7) to report smoking cigarettes than those who assessed their general health status to be excellent or good after adjusting for several demographic characteristics (Table 3). Women with frequent physical distress were more likely (OR 1.5; 95% CI 1.4–1.7) to smoke cigarettes than those who did not report such distress. Those with frequent mental distress (OR 2.0; 95% CI 1.9–2.1), frequent activity limitation (OR 1.6; 95% CI 1.4–1.8), depression (OR 2.2; 95% CI 1.9–2.5), frequent experiences of stress and anxiety (OR 1.9%; 95% CI 1.7–2.1), or frequent lack of rest (OR 1.5; 95%CI 1.4–1.7) were more likely to smoke cigarettes than those who did not report having such problems. The magnitude of the association was strongest for those who reported frequent mental distress or depression.
Similarly, among pregnant women, those who reported their general health to be fair or poor were more likely to report smoking cigarettes (OR 2.4; 95% CI 1.5–3.8). Pregnant women who reported frequent physical distress (OR 1.7; 95% CI 1.1–2.6) or mental health distress (OR 2.5; 95% CI 1.7–3.7) were more likely to report smoking cigarettes than pregnant women who did not report these. It is interesting to note that the magnitude of the association between 3 of the Health Related Quality of Life indicators (ie, fair or poor health, frequent mental distress, and frequent lack of rest) and smoking was stronger among pregnant than nonpregnant women.
Rates of alcohol use and binge drinking were lower among pregnant than among nonpregnant women. Because of the small numbers of women in the pregnant binge drinking category, we could not assess the association between Health Related Quality of Life indicators and binge drinking. As shown in Table 4, among nonpregnant women those with frequent mental distress (OR 1.2; 95% CI 1.1–1.3), frequent depression (OR 1.3; 95% CI 1.1–1.5), or frequent stress and anxiety (OR 1.3, 95% CI 1.1–1.5) were more likely to report drinking any alcohol in the previous month. Most Health Related Quality of Life measures were not found to be significantly associated with alcohol use among pregnant women.
Our findings show that women of reproductive age experience substantial amounts of physical and mental distress, depression, and stress and anxiety, and a high proportion do not get enough rest or sleep. Moreover, pregnant women were less likely than nonpregnant women to report fair or poor health and frequent mental distress but were more likely to report frequent physical distress and activity limitation. It is possible that some differences can be explained by biologic, physical, or psychological changes related to pregnancy and menstrual cycles.1,2
Our findings are consistent with those from studies in which women with physical or mental distress were more likely to engage in high-risk behaviors of cigarette smoking and substance misuse.3,4,16–23 Although fewer pregnant women reported smoking cigarettes, those who were experiencing poor overall health, frequent mental distress, or frequent lack of rest were significantly more likely to report smoking than those without such experiences. In general, the emotional health of reproductive-age women may be associated with engaging in high-risk behaviors such as substance misuse, which may have long-term consequences for them and their families.16–27,31 Available encounters between women and providers should be used to educate women and to focus on prevention, given that many women in the reproductive-age group could be at risk for having unintended pregnancies and may be experiencing mental or physical distress and engaging in high-risk behaviors.
Our findings are subject to several limitations. First, the cross-sectional nature of the data did not allow us to establish a causal relationship. Second, because the Behavioral Risk Factor Surveillance System is based on data from a telephone surveys, the results may not be generalizable to women who do not have telephones or use only wireless phones. Finally, we were unable to determine the stage of pregnancy from Behavioral Risk Factor Surveillance System data. However, we have a large representative sample of US reproductive-age women, which enabled us to examine a number of Health Related Quality of Life indicators and their association with high-risk behaviors.
Our findings highlight the importance of examining the association between mental and physical distress measured by Health Related Quality of Life indicators and high-risk behaviors. Providers should assess the mental health status of pregnant women during prenatal care visits and that of nonpregnant women during visits for routine checkups, family planning visits, and well-child visits for those with children. These visits provide opportunities to counsel and support to women engaging in high-risk behaviors or having difficulty coping with health conditions or social stressors. Public health agencies, organizations, and primary health care providers need to develop, implement, and promote integrated programs for women that take into account mental and physical health. Interventions that integrate social and behavioral health along with physical health would be useful for long-term behavior change that would benefit not only women but also their families.
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