The use of psychosocial stress scales in preterm birth research




Psychosocial stress has been identified as a potential risk factor for preterm birth. However, an association has not been found consistently, and a consensus on the extent to which stress and preterm birth are linked is still lacking. A literature search was performed with a combination of keywords and MeSH terms to detect studies of psychosocial stress and preterm birth. Studies were included in the review if psychosocial stress was measured with a standardized, validated instrument and if the outcomes included either preterm birth or low birthweight. Within the 138 studies that met inclusion criteria, 85 different instruments were used. Measures that had been designed specifically for pregnancy were used infrequently, although scales were sometimes modified for the pregnant population. The many different measures that have been used may be a factor that accounts for the inconsistent associations that have been observed.


Healthy People 2010 set a goal of reducing preterm births in the United States from the 1998 baseline of 11.6% to 7.6%. However, the number of preterm births has been increasing steadily. In 2006, 12.8% of all births, or approximately one-half of 1 million newborn infants, were delivered at <37 weeks of gestation. There are multiple known risk factors that are associated with preterm birth, although 50% of the women who deliver prematurely have no clearly delineated risk factor. Although socioeconomic status and psychosocial stress both have been associated with preterm birth, the specific biologic mechanisms that links these factors to preterm birth and to disparities in preterm birth remain unclear. Moreover, the associations themselves have not been demonstrated consistently.


Investigators, as far back at the 1940s, who have explored the association of psychosocial stress with perinatal outcomes, have used numerous measures to quantify the presence of stress. Initial studies defined stress in terms of major life events, such as the death of a loved one or a large-scale environmental disaster. However, assessing life events may not ascertain the stress that pregnant women are most exposed to, given the low number of major acute life events that typically occur in pregnant women and the additional contribution that may exist from chronic stress. Indeed, in some studies, stressors more reflective of life-course stress have been shown to have a greater association with pregnancy outcomes. Furthermore, a woman’s experience in dealing with the aftermath of life stressors may be more relevant in the determination of her health status than any 1 particular stressful event. As a result, investigators have diversified their definition and measurement of psychosocial stress to include perceived stress, anxiety, depression, racism, lack of social support, coping mechanisms, job strain, acculturation stress, and domestic violence. Newer concepts include those that apply directly to pregnancy states, such as pregnancy-related anxiety and pregnancy intendedness.


As measures of stress have evolved, so have definitions of relevant pregnancy outcomes. Two literature reviews that were published in the 1990s noted that most of the studies that have been concerned with stress and pregnancy outcomes have consolidated a diverse spectrum of pregnancy and intrapartum events into 1 outcome variable: “complications in pregnancy.” Additionally, early efforts at estimating maturity used low birthweight or a birthweight of <2500 g as a proxy measure for preterm birth, given that gestational age often was measured inaccurately, particularly in the pre-ultrasound era. Although low birthweight is associated with significant morbidity and mortality rates, it has been identified as an imprecise gauge of prematurity because it encompasses both growth-restricted and premature infants.


Despite many years of research, a clear consensus on the contribution of psychosocial stress to preterm birth is still lacking. One potential cause for the inconsistent association that has been observed between stress and preterm birth is the extensive variability in the measures that are used for both psychosocial stress and pregnancy outcomes. The purpose of this study was to characterize the spectrum of psychosocial stress scales that are used in the existing preterm birth literature.


Materials and methods


Search strategy


A literature search was performed with MEDLINE, PsycINFO, EMBASE, and HAPI databases with a combination of keywords and MeSH terms that included psychosocial stress , maternal stress , chronic stress , life events , self-reported stress , anxiety , depression , domestic violence , social support , preterm birth , premature birth , and low birthweight . The literature search was performed by 1 researcher; however, if any questions arose regarding findings in individual articles, a second researcher reviewed the article, and the 2 researchers reached an agreement. Only articles published after 1970 were included in this assessment, given that studies conducted before that time are generally considered to be less rigorous in design. The most recent article included in this analysis is from January 2010. The references of retrieved articles were reviewed for additional publications that were not captured in the original search; these articles were then retrieved as well. This process was continued iteratively until no additional publications that met criteria for inclusion were found.


Study selection criteria


Abstracts of articles that were obtained from the search were assessed for suitability based on 2 criteria: (1) the study measured the exposure variable of psychosocial stress with a scaled instrument, and (2) the outcome variable included preterm birth or low birthweight.


Studies were excluded if authors did not distinguish preterm birth or low birthweight from a larger category of adverse pregnancy outcomes when conducting their analyses. Studies that evaluated the effect of psychosocial interventions on preterm birth or low birthweight delivery also did not meet criteria for inclusion. Additionally, if multiple articles were published from the same study, only 1 article was included to avoid over-counting the same instrument. Finally, only articles that were published in English were reviewed.


Scale selection criteria


Many authors developed their own questions to assess psychosocial stress. However, only scales that had been validated previously and were referenced explicitly were included. Finally, if the scale validation studies were not written in English or were unavailable through a literature or internet search, the instrument could not be assessed in terms of its psychometric properties and therefore was excluded from this study.


Data extraction


The data that were extracted from each article consisted of the study design; the names of the psychosocial instruments that were used; the number of times, the gestational ages when, and the method (self or via interviewer) by which the instruments were administered; the outcomes that were assessed; the presence of attempts to control for confounding, and the magnitude of association between psychosocial stress and a preterm or low birthweight delivery.


Analysis


A descriptive analysis of the included studies was conducted. To organize the data, we categorized the instruments into 4 domains of stress (ie, external stressors, perceived stress, enhancers of stress, and buffers of stress) based on a construct that had been published in the literature. Examples of external stressors are objective life events or daily hassles, perceived stress that reflects subjective stress levels and perceptions of racial or gender discrimination, enhancers of stress encompass anxiety or depression, and buffers of stress that cover a variety of social support systems and coping mechanisms. Within each domain of stress, subcategories of instruments that measure the same aspect of psychosocial stress were formed. Instruments that did not fit into any of the 4 domains were placed into an “other” category. The psychometric properties of each instrument and its frequency of use in the literature were also reported.


This study was exempt from institutional review board approval.




Results


Description of studies


The literature search yielded 200 articles for abstract review. Of those, 136 articles met inclusion criteria for analysis. Many studies were excluded because of the lack of a validated instrument to measure the exposure (n = 38), with the next most common reason being the use of a composite outcome of “complications of pregnancy” (n = 22). Four articles were judged to have duplicative information. Of note, both of the articles by Omer et al each included 2 separate studies that accounted for a total of 138 studies from 136 articles.


Table 1 outlines characteristics of the included studies. Most were prospective cohort studies, and the studies were split between those in which participants self-administered the instrument and those in which the participants were interviewed. Most of the questionnaires were administered 1 time. The studies were split evenly in terms of outcome measured. Nearly 90% of the analyses controlled for confounding factors.



TABLE 1

Characteristics of studies that examined psychosocial stress and pregnancy outcomes (n = 138)

































































































Variable Percentage
Study design
Cohort
Prospective cohort 73.9
Retrospective cohort 2.2
Case control 15.9
Cross sectional 8.0
Method of data collection
Interview 52.2
Self-report 38.4
Interview and self-report 7.2
Unknown 2.2
No. of times of survey administration
1
First trimester 1.4
Second trimester 18.8
Third trimester 8.0
Labor and delivery 2.2
Postpartum period 23.9
Unknown 15.9
2 14.5
3 8.7
4 5.8
6 0.7
Main outcome measured
Preterm birth or gestational age 29.7
Low birthweight or birthweight 30.4
Both gestational age and birthweight 39.9
Controlled for potential confounding variables
Yes 86.2
No 13.8

Chen. Psychosocial stress scales and preterm birth. Am J Obstet Gynecol 2011.


Description of psychosocial stress scales


A total of 85 instruments were used in the reviewed studies. The breakdown by domain is as follows: external stressors (n = 18), perceived stress (n = 13), enhancers of stress (n = 22), buffers of stress (n = 22), and other (n = 10). For each psychosocial stress instrument, a description of the scale, its psychometric properties, and the number of studies in which it appears are presented in Tables 2-6 .



TABLE 2

Psychosocial scales that measured external stressors




















































































































































































Name and description of scale Psychometric properties Studies, n Associated with decrease in gestational age or preterm birth Not associated with decrease in gestational age or preterm birth Associated with decrease in birthweight or low birthweight Not associated with decrease in birthweight or low birthweight
Daily chronic stressors



  • Daily Hassles Scale (Kanner et al, 1981 ): 117 items with 8 subscales of future security, time pressures, work, household responsibilities, health, inner concerns, financial responsibilities, and neighborhood/environment, within past month; scores include frequency of hassles and intensity calculated by cumulative severity/frequency




  • In community sample of middle-aged adults: test-retest reliability over months on average for frequency (0.79) and intensity (0.48); frequency of hassles has significant positive correlation with negative affect score (r = 0.22), with life events (r = 0.21), and with psychologic symptoms on Hopkins Symptom Checklist (HSCL; r = 0.60); frequency of hassles is more powerful predictor of HSCL score than life events

5 Modified version a , Health subscale ( P = .03) ; inner concerns subscale ( P = .03) ; financial responsibility subscale ( P = .02) References a ,
Everyday Problems Checklist (EPCL; Vingerhoets, 1994 ): 114 items about daily stressors that include family life, living and working conditions, physical appearance, transactions, and business in the past 2 months; scores include (1) frequency, (2) mean severity score, (3) product of 2 scores (total score)


  • In Dutch studies: test-retest reliability over 1 wk for frequency (0.87), severity (0.76), and total score (0.85); validity of EPCL scores correlate positively with distress; EPCL scores directly influence subjective health complaints, immune activity, and cardiovascular function

2 109-item version ( P < .01) Reference
Major life events
Life Experiences Survey (LES; Sarason et al, 1978 ): 57-item checklist of life events in past year; events rated as positive or negative and perceived impact of event; score summed as positive change, negative change, and total change


  • In college students: test-retest reliability for positive change score (0.53), negative change score (0.88), total change score (0.64); validity of total and negative change scores correlate positively with the State-Trait Anxiety Inventory; positive score not correlated; negative change score correlates with Beck Depression Inventory; total and positive scores not correlated

6 White women with high stress, RR, 1.8 (95% CI, 1.2–2.8) ; white women with few positive life events ( P < .01) ; modified 39-item, RR, 1.6 (95% CI, 1.1–2.3) Modified 39-item ; references Reference
Social Readjustment Rating Scale (SRRS; Holmes and Rahe, 1967 ): the SRRS is an adaptation of the Schedule of Recent Events with associated magnitude weightings for intensity and length of time necessary to accommodate the life event for each of 43 life events; scores include item frequency and life-change score (sum of item frequency times item weighting). In adult convenience sample: high correlations for magnitude of event weightings among each subgroup (0.820–0.975), and coefficient of concordance for all individuals (0.477; P < .0005); test-retest reliability over 2 wk to 5 mo (0.78–0.83); validity demonstrated by ability to predict health change with higher life-change score 7 27-item version: white women with high number of life events in first and second trimesters ( P = .04) ; for events in previous 2.5 y through pregnancy ( P < .01) For events in previous 6 mo ; for events in previous 2 y through pregnancy 11-item version: white women with high cumulative stress ( P < .01) ; modified version ( P < .05) ; money-related stressors ( P < .001) For events in previous 6 mo
Interview for Recent Life Events (IRLE; Paykel, 1969 ): modified from Holmes and Rahe’s SRRS, IRLE has 64 events organized into 10 categories of work, education, finance, health, bereavement, migration, cohabitation, legal, family and social relationships and marriage; for each event, respondent reports month of occurrence, independence of event from psychiatric illness, and objective negative impact.


  • In psychiatric patients: interrater reliability for specific event occurrence, month, independence, and objective negative impact (0.76–0.95); validity demonstrated by ability of instrument to differentiate patient and control groups in terms of number, timing, and qualities of events

3 References References
Life Events Inventory (LEI; Cochrane, 1973 ): modified from Holmes and Rahe’s SRRS, 35-item check list with additional 16 items for those who were ever married and 4 items for those who were never married.


  • In psychiatric patients, psychiatrists, and university students: the amount of “turmoil, disturbance, and upheaval” of each item was scored on scale from 1–100, with marriage as comparison score of 50; coefficient of concordance for all 3 groups (0.89).

1 Reference Reference
Modified Life Events Inventory (Newton, 1979 ): modified from Cochrane’s LEI, 59-item checklist of events validated in pregnant women. In pregnant women: 2 groups of pregnant women at different hospitals scored each item according to the amount of “worry, disruption, or upheaval” on scale of 1-100; scores >60 were considered major life events; women in both groups produced an identical list of 28 major life events. 6 More major life events ( P < .02) ; more objective life events ( P = .001) Case control study ; prospective cohort study ; 2 items regarding physical violence ; 27-item version More objective life events ( P = .004) 2 items regarding physical violence
Life Events Checklist (Johnson, 1980 ): 46-item checklist of life events related to child and adolescent life stress within past year; positive and negative life-change scores derived from sum of positive or negative impact of event ratings.


  • In youth aged 10-17 y: test-retest reliability after 2 wks for positive (0.69) and negative life-change score (0.72); interrater reliability between children and their mothers for positive (0.48) and negative life-change score (0.60); validity of negative life-change scores correlate with reports of personal and physical health problems; negative life-change scores correlate with depression, anxiety, and external locus of control; positive life-change scores correlate with internal locus of control.

2 References
Psychiatric Epidemiology Research Interview Life Events Scale (Dohrenwend, 1978 ): 102 events related to school, work, love and marriage, children, family, residence, crime and legal matters, finances, social activities, and health. In adults living in New York City: the severity of 101 events was rated in relation to marriage; the severity of 60 events were “consensual” or agreed on, 22 were “status dependent,” and 19 were “noisy” or indeterminate. 3 Stressful life events during pregnancy ( P = .001) References
Life Events and Difficulties Schedule (Brown, 1978 ): semistructured interview about the severity of events and difficulties in the areas of health, role changes, leisure, employment, housing, money, crises, forecasts, marriage, interactions with parents, and resources in the last 12 months. In female psychiatric and healthy women: interrater reliability (>0.90); validity: patients and their relatives had 81% agreement about the occurrence and onset of the same stressful event; patients reported more life events than healthy women; in terms of recall, there was little fall-off of events reported throughout year. 2 P < .001 21-item version
Life Events Questionnaire (LEQ; Norbeck, 1984 ): 82-item checklist of events designed for female adults of childbearing age; life events pertain to health, work, school, residence, love and marriage, family and close friends, parenting, personal and social, financial, and crime and legal matters; scores include negative events, positive events, and total events scores.


  • In female nursing students and mothers: test-retest reliability over 1 wk (0.78–0.83); validity: LEQ negative-events score highly correlated with total negative moods on Profile of Mood States scale (POMS; r = 0.34); LEQ positive-events score correlated with vigor-activity mood from POMS; LES negative-events score highly correlated with Brief Symptom Inventory summary scores for psychiatric symptoms (r = 0.30–0.39)

2 References Reference
Prenatal Social Environment Inventory Scale (PSEI; Orr, 1992 ): 41-item checklist of chronic life stressors and major stressful events that pregnant women have experienced in the past 12 mo. In pregnant women: internal consistency (0.80); test-retest reliability over 30 d (0.73); validity: PSEI significantly and positively correlates with the Center for Epidemiologic Studies Depression scale ( P = .001) 4 6-item anxiety subscale, medium anxiety (RR, 1.5; 95% CI, 1.1–2.1) and high anxiety (RR, 2.1; 95% CI,1.5–3.0) ; 6-item anxiety subscale, African American women with high anxiety (RR, 2.0; 95% CI, 1.3–3.2) and white women with high anxiety (RR, 1.6; 95% CI, 1.1–2.3) ; 6-item anxiety subscale, score of 5 of 6 (OR, 1.70; 95% CI, 1.01–2.87) and score of 6 of 6 (OR, 2.73; 95% CI, 1.03–7.27) African American women with high stressors ( P = .05)
Family Inventory of Life Events (FILE; McCubbin, 1982 ): 71 items that measure stressful events for the family in previous 12 mo; 17-item subscale for intra-family strain and 54 items for strains in marriage, pregnancy, work, finances, health, legal matters, home transitions, and losses.


  • In families and students: internal consistency of total scale (0.79–0.81), intra-family subscale (0.71–0.73), and all other subscales (0.09–0.71); test-retest reliability after 5 wks for total scale (0.80) and intra-family subscale (0.73); validity: FILE scores correlated with pulmonary functioning of children with cystic fibrosis; significant correlations between total or intra-family scores with other measures of cohesion, conflict, and family organization.

1 Reference
Trauma History Questionnaire (THQ: Green, 1995 ): 24 items about lifetime history of exposure to traumatic events in the areas of crime, disaster, and unwanted physical/sexual violence. In psychiatric outpatients with severe mental illness: test-retest reliability over 2 wks (0.76); criterion-related validity demonstrated by significant positive correlations with symptoms of posttraumatic stress. 1 Reference
Violence and abuse
Abuse assessment screen (AAS; Parker, 1991 ): 5 items identify victims of domestic violence and measures the frequency, severity, and sites of injury because of abuse.


  • In pregnant women: internal consistency reliability (0.83–1.0); concurrent validity when compared with the Index of Spouse Abuse (ISA-P = 0.355; ISA-NP = 0.297), Conflict Tactics Scale (severe violence subscale, 0.278), and Danger Assessment Screen (0.358; all P < .01); respondents who scored positive for abuse on AAS had higher score on ISA, Danger Assessment Screen, and CTS (except verbal reasoning subscale; P < .001).

19 Modified version, RR, 1.7 (95% CI, 1.1–2.6) ; teenagers: OR 3.5 (95% CI, 1.1–10.8) ; OR, 2.8 (95% CI, 1.3–5.9; P = .01) ; RR, 2.5 (95% CI, 1.4–4.1) ; OR, 1.6 (95% CI, 1.1–2.3) ; OR, 3.1 (95% CI, 2.0–4.9) References ; 3-item version


  • Modified version, RR, 2.0 (95% CI, 1.4–3.1) ; OR, 5.0 (95% CI, 1.3–19.1; P = .02) ;



  • RR, 2.5 (95% CI, 1.4–4.5) ; OR, 1.8 (95% CI, 1.3–2.5) ; 3-item version ( P < .05) ; RR, 3.8 (95% CI, 2.9–5.0) ; RR, 1.5 (95% CI, 1.1–2.2) ; OR, 4.0 (95% CI, 1.7–9.3) ; OR, 2.4 (95% CI, 1.1–5.6)

References
Conflict Tactics Scale (CTS; Straus, 1979 ): 19 items that measure method of dealing with conflict within families; 3 subscales of reasoning, verbal aggression, and violence.


  • In national sample of couples: internal consistency of reasoning (0.76), verbal aggression (0.88), and violence (0.88); concurrent validity: sociology students reported similar incidence rates of violence by each parent when compared with each spouse’s report of violence; content validity: each item on violence subscale describes an act of actual physical force; construct validity: high level of violence when power structure is unequal between partners.

5 10-item version ; reference Modified version, OR, 10.2 (95% CI, 1.4–73.9; P = .015) 10-item version ; reference ; violence subscale
Index of Spouse Abuse (ISA; Hudson, 1981 ): 30 items that measure severity of physical (ISA-P) and nonphysical abuse (ISA-NP) by partner. In college/graduate students: internal consistency reliability (ISA-P = 0.90; ISA-NP = 0.91); construct validity: ISA discriminated between clinically abused and nonabused groups better than other clinical scales not related to abuse (ISA-P = 0.73; ISA-NP = 0.80). 1 Reference
HITS scale (Sherin, 1998 ): 4 items ask whether respondent has been physically Hurt, Insulted, Threatened, or Screamed at.


  • In family practice office patients: internal consistency reliability (0.80);



  • concurrent validity with CTS (total score, 0.85; physical abuse, 0.82, verbal abuse, 0.81); construct validity: HITS score higher for victimized vs nonvictimized ( P < .0005).

1 Verbal abuse ( P = .002)

CI , confidence interval; OR , odds ratio; RR , relative risk.

Chen. Psychosocial stress scales and preterm birth. Am J Obstet Gynecol 2011.

a In study by Wadhwa et al, the scores from the Daily Hassles Scale, Cohen’s Perceived Stress Scale, and Hopkins Symptom Checklist were combined to create a composite measure of “perceived stress” for analysis.



TABLE 3

Psychosocial stress scales that measure perceived stress




















































































































































Name and description of scale Psychometric properties Studies, n Associated with decrease in gestational age or preterm birth Not associated with decrease in gestational age or preterm birth Associated with decrease in birthweight or low birthweight Not associated with decrease in birthweight or low birthweight
Subjective stressors



  • Perceived Stress Scale (PSS; Cohen et al, 1983 ): 14 items that measure degree to which lives are unpredictable, uncontrollable, and overloading in the last month.




  • In college students and community group enrolled in smoking-cessation program: internal consistency reliability (0.84–0.86); test-retest reliability over 2 d (0.85) and over 6 wk (0.55); validity demonstrated by significant positive correlation between higher PSS scores and subjective rating of life events; predictive validity: compared with the number of life events, PSS scores were a better predictor of depressive and physical symptoms, use of health services, and social anxiety.

18 5-item version ( P < .03) a ; 8-item version ( P < .05) ; 12-item version (OR, 2.8; 95% CI, 1.3–5.9; P < .01) ; 4-item version for Aboriginal Canadian women (OR, 7.6; 95% CI, 1.1–50.9) ; P = .04 ; 4-item version (OR, 1.5; 95% CI, 1.1–1.9) ; 10-item version ( P < .0004) ; 8-item version ( P < .05)


  • “Short form” ;



  • 4-item version ; 14-item version b , ; 12-item version ; 8-item version ; 10-item version

5-item version ( P < .01) a


  • 4-item version ; 14-item version b , ; 12-item version ; 8-item version ; 10-item version ; 14-item version

Impact of Event Scale (IES; Horowitz, 1979 ): 15 items that measure psychologic impact of a variety of traumas in the past 7 days; 2 subscales of intrusion and avoidance.


  • In adult psychotherapy patients, physical therapy, and medical students: internal consistency for intrusion (0.78) and avoidance (0.82); split-half reliability (0.86); test-retest reliability after 1 wk for total scale (0.87), intrusion (0.89), and avoidance (0.79); validity: after time and psychotherapy treatment, patient scores on IES improved, which reflects the scale’s sensitivity to change; psychotherapy patients had higher IES scores than medical students, which shows scale’s ability to discriminate between groups with different traumas.

1 5-item version of intrusion subscale 5-item version of intrusion subscale ( P < .01)
Subjective Stress Scale (Schar, 1973 ): 4 statements regarding perceived stress with daily activities.


  • In German male factory workers: item intercorrelations range from 0.38–0.54; subjective stress scale correlates with other psychosocial measures of work satisfaction, social stress, and neuroticism; subjective stress scale scores correlate with personal and familial cardiovascular disease.

2 Reference In women with body mass index <22 kg/m 2 ( P = .009) Reference
Work strain
Job Content Questionnaire (JCQ; Karasek et al, 1985 ): 49 items that measure job characteristics with subscales of decision latitude, psychologic demands, social support, physical demands, and job insecurity; job strain , defined as high psychologic demands and low decision latitude, leads to psychologic strain. In multiple international study populations: internal consistency (0.58–0.86); predictive validity: multiple studies show that JCQ scores predict chronic disease states, such as cardiovascular disease, mental strain, and occupation injury. 11


  • References ;



  • “abbreviated version” ;



  • 14-item version

12-item version (OR, 1.8; 95% CI, 1.0–3.3) ; high-strain job associated with birthweight difference of 190 g (95% CI, 48–333 g) ; P < .01) References



  • Occupational Fatigue Index (Mamelle et al, 1984 ): 5 items regarding posture, work on industrial machine, physical exertion, mental stress, and environment.




  • In pregnant women: internal consistency reliability not applicable; validity demonstrated by ability to predict negative pregnancy outcomes.

4


  • Score ≥3 ( P < .05) ; 4-item version (OR, 1.4; 95% CI,1.1–1.9; P < .02)

References
Effort-Reward Imbalance Questionnaire (ERI-Q; Siegrist et al, 1996 ): 23 items determine chronic stress resulting from imbalance between high effort and low rewards with the use of subscales to measure effort, reward, and over-commitment.


  • In working adults from 5 European studies: internal consistency of effort (0.61–0.78), reward (0.70–0.88), and over-commitment (0.64–0.82); content validity: those with high effort-reward ratios and high over-commitment report poor self-rated health; factorial analysis showed that constructs were consistent across all populations.

1 Reference
Racial discrimination



  • Experiences of Discrimination (EOD; Krieger et al, 1990 ): based on previous instrument used in the Coronary Artery Risk Development in Young Adults study; 7- or 9-item instrument includes questions about response to unfair treatment and situations in which subjects experience discrimination.




  • In working class white, African American, and Latino adults: internal consistency (0.74–0.87); test-retest reliability after 2–4 wk (0.69–0.72); validity: EOD scores correlate with other measures of discrimination (r = 0.79); EOD scores are associated with psychologic distress and not associated with social desirability.

5 In African American women (RR, 1.8; 95% CI, 1.1–2.9) ; ≥3 experiences of discrimination (OR, 3.1; 95% CI, 1.3–7.2) References ≥3 experiences of discrimination (OR, 2.6; 95% CI, 1.2–5.3) ; P < .01) Reference



  • Perceived Racism Scale (McNeilly et al, 1996 ): 51 items that measure African-American perceptions of racism from white Americans in terms of the frequency of exposure, the emotional responses, behavioral coping mechanisms, and the situation in which racism is encountered.




  • In African American students and community residents: internal reliability (0.87–0.96); test-retest reliability after 2 wk for frequency of exposure (0.71–0.80) and emotional and coping responses (0.50–0.78).

1 Reference



  • Everyday Discrimination Scale (EDS; Forman, 1997 ): 9 items that measure the presence, frequency, and source of chronic and routine experiences of discrimination.




  • In African American high school students: internal consistency (0.87); split-half reliability (0.83); criterion-related validity- EDS scores have a significant positive correlation with externalizing (r = 0.34) and internalizing (r = 0.39) symptoms that were significantly more common in persons who reported discrimination compared with those who did not.

1 Discrimination because of age ( P = .04) and physical disability ( P < .001)
Perceptions of Racism Scale (PRS; Green, 1995 ): 20 items that measure perception of racism in terms of feelings of racism, experience of racist actions, and racist thoughts in African American women.


  • In pregnant African American women: internal consistency (0.91); content validity: scale items were critiqued by experts; concurrent validity: positive relationship between stress and perceived racism ( P < .01).

1 Reference Reference
Other scales
Prenatal Distress Questionnaire (PDQ; Yali and Lobel, 1999 ): 12 items assess the worries and concerns that a woman has about different aspects of pregnancy that include physical and emotional symptoms, relationships, body image, and mothering ability.


  • In pregnant women: internal consistency (0.81); validity: items were developed from descriptive studies of women’s concerns during pregnancy; PDQ measures similar constructs as other prenatal stress scales; PDQ scores only moderately correlate with nonspecific, global distress, which suggests a difference between global and pregnancy-specific distress.

3 P < .008 References Reference
Maternal Adjustment and Maternal Attitudes (MAMA; Kumar et al, 1984 ): 60 items with 5 subscales that measure mother’s perceptions of her body, somatic symptoms, marital relationship, attitudes to sex, and attitudes to the pregnancy and the baby in the past month.


  • In pregnant women: split-half reliability (0.58–0.82); test-retest reliability over 1 wk (0.81–0.95); criterion-related validity: interviews about somatic symptoms, marital relationship, attitudes to sex, and attitudes to baby were comparable with corresponding MAMA subscale.

1 Reference



  • Marital Strain Scale (Pearlin and Schooler, 1978 ): 14 items that measure chronic stress from a woman’s partner in terms of nonacceptance by spouse, nonreciprocity, and frustration of role expectations.




  • In parents: reliability (0.89); Pearlin’s Marital Strain scale correlates with Dohrenwend’s marital functioning scale (r = 0.83), which indicates a lack of discriminant validity.

1 Reference

CI , confidence interval; OR , odds ratio; RR , relative risk.

Chen. Psychosocial stress scales and preterm birth. Am J Obstet Gynecol 2011.

a In Lobel’s study, Cohen’s Perceived Stress Scale, Spielberger’s State Anxiety subscale, and a measure of stressful prenatal life events were included as a latent stress factor for modeling purposes;


b In Wadhwa’s study, the score from the Hopkins Symptom Checklist was combined with those on the Daily Hassles Scale and Cohen’s Perceived Stress Scale to create a composite measure of “perceived stress” for analysis.



TABLE 4

Psychosocial stress scales measuring enhancers of stress




















































































































































































































Name and description of scale Psychometric properties Studies, n Associated with decrease in gestational age or preterm birth Not associated with decrease in gestational age or preterm birth Associated with decrease in birthweight or low birthweight Not associated with decrease in birthweight or low birthweight
Depression
Center for Epidemiologic Studies Depression scale (CES-D; Radloff, 1977 ): 20 items that measure symptoms of depression and their frequencies in the past week in the general population; score of 16 is cutoff for depression.


  • In general households and psychiatric patients:



  • internal consistency in general (0.85) and patients (0.90); test-retest reliability over 2-8 wk (0.57); validity: patient scores were significantly higher than scores of general population; CES-D correlates with other self-report scales for depression or general psychopathology.

18


  • OR, 1.4 (95% CI, 1.01–2.1) ; P = .05 ; score ≥24 and receiving psychiatric medications (OR, 2.0; 95% CI, 1.1–3.6) ; 16-item version (OR, 1.04; 95% CI, 1.01–1.07; P < .01) ; score ≥22 (hazard ratio, 2.2; 95% CI, 1.1–4.7) ; OR, 1.96 (95% CI, 1.04–3.72)




  • References ;



  • “short form” ;



  • 16-item version

In women with body mass index <22 ( P = .005) ; P = .05) ; 16-item version ( P < .001) References
Beck Depression Inventory (BDI; Beck et al, 1961 ): 21 items that measure the severity of behavioral manifestations of depression that include mood, pessimism, sense of failure, lack of satisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideation, crying, irritability, social withdrawal, indecisiveness, body image, work, sleep disturbance, fatigue, loss of appetite, weight loss, somatic symptoms, and libido.


  • In psychiatric patients:



  • internal consistency (0.76–0.95);



  • split-half reliability (0.93);



  • test-retest reliability (0.48–0.86);



  • content validity: items constructed from clinical symptoms of depressed patients and reflect criteria in DSM-III;



  • concurrent validity: BDI scores correlate with clinical ratings of depression (r = 0.55–0.96), Hamilton Rating Scale for Depression (r = 0.61–0.86), and other depression scales;



  • discriminant validity: BDI scores are correlated more with clinical ratings of depression (r = 0.59) than anxiety (r = 0.14) and distinguish between psychiatric and nonpsychiatric patients; construct validity: BDI scores are related to suicide and alcoholism, maladjustment, and a variety of medical symptoms.

5 BDI-II version (OR, 1.06; 95% CI, 1.01–1.11)


  • Reference ;



  • BDI-II version

BDI-II version (OR, 1.07; 95% CI, 1.02–1.12) References ; BDI-II version
Edinburgh Postnatal Depression Scale (EPDS; Cox et al, 1987 ): 10 items originally developed for measuring severity of postpartum depression symptoms but has been validated for use in nonpostpartum women.


  • In nonpostpartum and postpartum mothers:



  • nonpostpartum women, sensitivity (88%), false positive rate (20%), positive predictive value (21%); postpartum women, sensitivity (75%), false positive rate (16%), positive predictive value (24%).

3


  • OR, 3.3 (95% CI, 1.2–9.2; P = .02) ;



  • P < .001)

References
Hamilton Rating Scale for Depression (HAM-D; Hamilton, 1960 ): 17 items originally developed as clinician-rated scale in patients already diagnosed with depression; items assess depressed mood, suicide, loss of interest, psychomotor agitation and retardation, insight, loss of weight, gastrointestinal symptoms, and hypochondriasis.


  • In multiple study patients:



  • internal consistency (0.48–0.92);



  • interrater reliability (0.70–0.96);



  • test-retest reliability (0.65–0.96);



  • concurrent validity: HAM-D scores correlate with other instruments for depression, such as BDI (r = 0.56–0.92), and global measures of mental health (r = 0.65–0.90);



  • discriminant validity: HAM-D can distinguish between depressed and not depressed respondents; HAM-D scores are sensitive to changes over time with treatment.

1 Reference
Anxiety
State-Trait Anxiety Inventory (STAI; Spielberger, 1983 ): 1 20-item scale that measures state or transitory anxiety experienced at that moment; the other 20-item scale measures trait anxiety or propensity towards anxiety, based on personality.


  • In students, working adults, and military recruits: internal consistency for trait anxiety (0.90) and state anxiety (0.93); test-retest reliability after 20–104 d for trait anxiety (0.73–0.86) and state anxiety (0.33);



  • construct validity of state anxiety scale was demonstrated by higher scores in stressful situations and lower scores in relaxed situations; concurrent validity: trait anxiety scores were correlated with Cattell’s IPAT Anxiety Questionnaire and Taylor’s Manifest Anxiety Scale score (r = 0.73–0.85).

20


  • State anxiety subscale ( P < .03) a ; state anxiety subscale ( P < .05) ; 10-item version of state anxiety subscale ( P < .01) ; trait anxiety subscale ( P < .05) and state anxiety subscale ( P < .01)




  • References ;



  • trait anxiety subscale ; state anxiety subscale ; 10-item version of state anxiety subscale




  • State anxiety subscale ( P < .01) a ; African American women ( P = .03) ; women with body mass index <22, trait anxiety subscale ( P = .0002)

References ; 10-item version of state anxiety subscale ; state anxiety subscale ; trait anxiety subscale
Manifest Anxiety Scale (MAS; Taylor, 1953 ): 50 true or false statements that assess anxiety; items were adapted from the Minnesota Multiphasic Personality Inventory (MMPI).


  • In college students and psychiatric outpatients:



  • test-retest reliability after 4 wk (0.88); validity: MAS scores are moderately correlated with MMPI (r = 0.68); patients score higher on manifest anxiety than healthy individuals.

1 Reference
Hamilton Rating Scale for Anxiety (HAM-A; Hamilton, 1959 ): 14-item interview scale designed for the assessment of anxiety symptoms in patients who were already diagnosed with anxiety states; instrument has 2 subscales of psychic anxiety and somatic anxiety.


  • In psychiatric patients: interrater reliability for total scale (0.74), psychic anxiety (0.73), and somatic anxiety (0.70);



  • concurrent validity: HAM-A scores correlate with Covi Anxiety scale (r = 0.63); HAM-A scores are sensitive to changes in clinical status.

1 P = .01



  • Institute for Personality and Ability Testing Anxiety Scale (IPAT; Cattell, 1963 ): 40 items that measure indirect and overt manifestations of anxiety.




  • In nursing and college students: test-retest reliability after 2-3 wk (0.94); criterion validity: IPAT scores not related to clinical ratings of anxiety or with other instruments for the measurement of anxiety; IPAT scores were higher in students exposed to hypnotically induced anxiety and those infused with hydrocortisone than in control students.

1 P < .0005
Karolinska Scales of Personality (KSP; Schalling, 1977 ): 135 items with 15 subscales that measure personality traits, psychic and somatic anxiety, muscular tension, lack of energy and assertiveness, detachment, impulsivity, sensation seeking, socialization, indirect and verbal aggression, irritability, suspicion, guilt, and social desirability.


  • In college students: internal consistency of subscales (0.35–0.78); factor analysis revealed 4 factors of negative emotionality, aggressive nonconformity, impulsive unsocialized sensation seeking, and social withdrawal; KSP factors correlate with Eysenck Personality Questionnaire (EPQ) subscales: EPQ neuroticism relates to KSP negative emotionality; EPQ extraversion relates to KSP social withdrawal; and EPQ psychoticism relates to KSP aggressive nonconformity and impulsive unsocialized sensation seeking.

1 Somatic and psychic anxiety subscale ( P > .05) Reference
Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al, 1997 ): 38-item screening tool for anxiety disorders in children aged 9-18 y that measures 5 factors of somatic/panic symptoms, general anxiety, separation anxiety, social phobia, and school phobia.


  • In children and parents: internal consistency for total score (0.93) and factor values (0.74–0.89); test-retest reliability after 5 wk for total score (0.86) and for factors (0.70–0.90); discriminant validity: SCARED scores were significantly different between children with anxiety disorders and those with nonanxiety psychiatric disorders.

1 Reference
Composite measures of mental well-being
General Health Questionnaire (GHQ; Goldberg, 1979 ): screening tool for the detection of psychiatric illness through items regarding disruptions in the performance of daily activities and feelings of subjective distress; 12-, 28-, 30-, and 60-item versions.


  • In psychiatric patients: internal consistency of GHQ-30 (0.84–0.93); split-half reliability (0.95); validity for GHQ-28, sensitivity (86%) and specificity (82%); for GHQ-30, sensitivity (81%) and specificity (80%); median correlation between other similar instruments and GHQ-28 (r = 0.76) and GHQ-30 (r = 0.59).

9


  • 12-item version (relative risk, 2.3; 95% CI, 1.2–4.6; P = .015) ; 30-item version (relative risk, 1.8; 95% CI, 1.2–2.5)

References


  • 12-item version (relative risk, 2.0; 95% CI, 1.1–3.5) ; 12-item version (OR, 3.5; 95% CI, 1.5–8.2)




  • References ;



  • 22-item version

Hopkins Symptom Checklist (HSCL; Parloff, 1954 ): 58 items that measure 5 symptom dimensions of somatization, obsessive-compulsive, interpersonal sensitivity, depression, and anxiety.


  • In both patients and community members: internal consistency for 5 symptom dimensions (0.84–0.87); test-retest reliability after 1 wk (0.75–0.84); construct validity: HSCL symptom dimensions correspond highly with psychiatrist ratings of patients.

3 Reference b 34-item version (OR, 1.12; 95% CI, 1.01–1.24) Reference b



  • SCL-90 (Derogatis et al, 1973 ): modified from the HSCL, 90 items that measure 9 primary symptom dimensions in psychiatric outpatients that include somatization, obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid ideation, and psychoticsm; 3 global indices of distress are derived: Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total.




  • In drug trial volunteers: internal consistency of all subscales (0.77–0.90); test-retest reliability after 1 wk (0.78–0.90); convergent validity: SCL-90 subscale scores correlate with analogous measure in MMPI;



  • discriminant validity: subscales did not correlate with nonanalogous scales.

1


  • Increased anger-hostility subscales ( P < .05) ; paranoid ideation and psychoticism ( P < .005)

Brief Symptom Inventory (BSI; Derogatis, 1983 ): derived from the SCL-90, this 53-item scale that measures psychologic symptoms in psychiatric, medical, and healthy individuals; similar to the SCL-90, there are 9 primary symptom dimensions and 3 global indices of distress.


  • In psychiatric outpatients, psychiatric inpatients, and healthy individuals:



  • internal consistency (0.71–0.85); test-retest reliabilities after 2 wk for 9 symptom dimensions (0.68–0.91) and for 3 global indices (0.80–0.90); concurrent validity: BSI symptom dimensions correlate with analogous measure on MMPI; construct validity: factor analysis shows 7 of 9 symptom dimensions reproduced.

3 Reference Depression subscale ; reference
Profile of Mood States (POMS; McNair et al, 1971 ): 65 items that measure 6 dimensions of affect and mood, specifically tension-anxiety, depression-dejection, anger-hostility, vigor-activity, fatigue-inertia, and confusion-bewilderment.


  • In college students and psychiatric outpatients: internal consistency of POMS subscales (>0.84); test-retest reliability after 20 d (0.65–0.74) and after 9 wk (0.43–0.53); concurrent validity: POMS scores correlate with other personality measures and symptom checklists.

2 References Reference
Posttraumatic Stress Disorder Checklist (PCL; Weathers et al, 1993 ): 17 items assess severity of symptoms of PTSD in the last month, based on DSM-IIIR.


  • In war veterans: internal consistency (0.97); test-retest reliability over 2-3 d (0.96); convergent validity: PCL scores correlate with Mississippi Scale (r = 0.93), Impact of Event Scale (r = 0.90), and Combat Exposure Scale (r = 0.46); PCL as a predictor of PTSD diagnosis based on Structured Clinical Interview for DSM-IIIR: sensitivity (82%), specificity (83%).

1 Reference Reference
Crown-Crisp Experiential Index (CCEI; Crisp, 1966 ): previously known as the Middlesex Hospital Questionnaire, this scale has 48 items that examine psychoneurotic symptoms and traits with subscales of free-floating anxiety, depression, hysteria, phobic anxiety, obsessionality, and somatic anxiety.


  • In psychiatric patients and healthy adults: split-half reliability coefficients of all subscales (0.37–0.82); the obsessionality and somatic subscales have the lowest reliabilities; validity: subscale scores differed significantly between patients and healthy adults; similarly, clinician ratings differed significantly between patients and healthy adults with the use of all except the obsessionality subscale.

1 “Free floating anxiety” subscale
RAND Mental Health Index (Ware, 1985 ): 32 items that measure depression, anxiety, feelings of belonging, positive affect.


  • In outpatients: internal consistency reliability (α = .98); validity: mental and physical factors are distinguishable, and scales that measure aspects of mental health correlate more with each other than they do with scales that measure physical health variables.

1 Anxiety subscale ( P < .05)
Primary Care Evaluation of Mental Disorders (PRIME-MD; Spitzer et al, 1994 ): evaluates mood, anxiety, somatoform disorders, alcohol use, and eating disorders in the primary care setting; patients complete 26 yes/no questions for symptoms in last month, and clinicians follow up with 12-page evaluation guide; items correspond with diagnoses from DSM-III-R.


  • In primary care patients: interrater reliability between primary care doctors and mental health professionals for any psychiatric diagnosis (0.71); for any psychiatric diagnosis, sensitivity of PRIME-MD (83%), specificity (88%), positive predictive value (80%), overall accuracy rate (86%); construct validity: patients with PRIME-MD diagnoses have significantly impaired functioning and greater health care use; concurrent validity: PRIME-MD diagnoses correlated with corresponding self-rated symptom severity scales.

1 Reference Reference
Hospital Anxiety and Depression Rating Scale (HADS; Zigmond and Snaith, 1983 ): 14 items developed for the hospital setting with 7 items for symptoms of depression (HADS-D) and 7 items for symptoms of anxiety (HADS-A) experienced during the previous 7 d.


  • In medicine outpatients: internal consistency for HADS-D (0.3–0.6) and HADS-A (0.41–0.76); psychiatric severity rating has significant positive correlation with HADS-D score (r = 0.70) and HADS-A score (r = 0.74); patient and interviewer ratings were correlated for each subscale but were not correlated between contrary disorders (ie, HADS-A not correlated with HADS-D score).

1 Reference Reference
Anomie Scale (Srole, 1956 ): 5 items that measure individual’s sense of alienation.


  • In adults: coefficient of reproducibility (0.90) and coefficient of stability (0.65);



  • convergent validity: Anomie Scale scores correlate with social isolation and relate to negative attitudes towards minorities (r = 0.43).

1 African American women without Medicaid (OR, 1.8; 95% CI, 1.2–2.6)
State-Trait Personality Inventory (STPI; Spielberger, 1979 ): 80 items that measure anxiety, anger, curiosity, and depression, each as states and traits; 8 subscales with 10 items each.


  • In college students: internal consistency for state and trait depression subscales (0.90);



  • validity: trait depression subscale correlates higher with other scales that measure depression (r = 0.78) than state depression (r = 0.66); STPI depression subscales correlate positively with STPI anxiety and negatively with curiosity and has a weak correlation with anger.

2 State anxiety subscale (OR, 2.4; 95% CI, 1.2–5.0; P < .05) State anxiety subscale State anxiety subscale

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