Maternal and Child Health Journal

, Volume 15, Issue 7, pp 1011–1019 | Cite as

Self-Efficacy as a Mediator Between Maternal Depression and Child Hospitalizations in Low-Income Urban Families

  • Margaret L. Holland
  • Byung-Kwang Yoo
  • Harriet Kitzman
  • Linda Chaudron
  • Peter G. Szilagyi
  • Helena Temkin-Greener


The objective of this study is to examine the role of maternal self-efficacy as a potential mediator between maternal depression and child hospitalizations in low-income families. We analyzed data from 432 mother–child pairs who were part of the control-group for the Nurse-Family Partnership trial in Memphis, TN. Low-income urban, mostly minority women were interviewed 12 and 24 months after their first child’s birth and their child’s medical records were collected from birth to 24 months. We fit linear and ordered logistic regression models to test for mediation. We also tested non-linear relationships between the dependent variable (child hospitalization) and covariates (depressive symptoms and self-efficacy). Elevated depressive symptoms (OR: 1.70; 90% CI: 1.05, 2.74) and lower maternal self-efficacy (OR: 0.674; 90% CI: 0.469, 0.970) were each associated with increased child hospitalizations. When both maternal self-efficacy and depressive symptoms were included in a single model, the depressive symptoms coefficient decreased significantly (OR decreased by 0.13, P = 0.069), supporting the hypothesis that self-efficacy serves as a mediator. A non-linear, inverse-U shaped relationship between maternal self-efficacy and child hospitalizations was supported: lower compared to higher self-efficacy was associated with more child hospitalizations (P = 0.039), but very low self-efficacy was associated with fewer hospitalizations than low self-efficacy (P = 0.028). In this study, maternal self-efficacy appears to be a mediator between maternal depression and child hospitalizations. Further research is needed to determine if interventions specifically targeting self-efficacy in depressed mothers might decrease child hospitalizations.


Maternal depression Self-efficacy Healthcare utilization Child health Low income 


  1. 1.
    Chung, E. K., McCollum, K. F., Elo, I. T., Lee, H. J., & Culhane, J. F. (2004). Maternal depressive symptoms and infant health practices among low-income women. Pediatrics, 113(6), e523–e529.PubMedCrossRefGoogle Scholar
  2. 2.
    Guttmann, A., Dick, P., & To, T. (2004). Infant hospitalization and maternal depression, poverty and single parenthood—a population-based study. Child: Care, Health and Development, 30(1), 67–75.CrossRefGoogle Scholar
  3. 3.
    Sills, M. R., Shetterly, S., Xu, S., Magid, D., & Kempe, A. (2007). Association between parental depression and children’s health care use. Pediatrics, 119(4), e829–e836.PubMedCrossRefGoogle Scholar
  4. 4.
    Weil, C. M., Wade, S. L., Bauman, L. J., Lynn, H., Mitchell, H., & Lavigne, J. (1999). The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma. Pediatrics, 104(6), 1274–1280.PubMedCrossRefGoogle Scholar
  5. 5.
    Kahn, R. S., Zuckerman, B., Bauchner, H., Homer, C. J., & Wise, P. H. (2002). Women’s health after pregnancy and child outcomes at age 3 years: A prospective cohort study. American Journal of Public Health, 92(8), 1312–1318.PubMedCrossRefGoogle Scholar
  6. 6.
    Minkovitz, C. S., Strobino, D., Scharfstein, D., Hou, W., Miller, T., Mistry, K. B., et al. (2005). Maternal depressive symptoms and children’s receipt of health care in the first 3 years of life. Pediatrics, 115(2), 306–314.PubMedCrossRefGoogle Scholar
  7. 7.
    Flores, G., Abreu, M., Chaisson, C. E., & Sun, D. (2003). Keeping children out of hospitals: Parents’ and physicians’ perspectives on how pediatric hospitalizations for ambulatory care-sensitive conditions can be avoided. Pediatrics, 112(5), 1021–1030.PubMedCrossRefGoogle Scholar
  8. 8.
    Hakim, R. B., & Bye, B. V. (2001). Effectiveness of compliance with pediatric preventive care guidelines among medicaid beneficiaries. Pediatrics, 108(1), 90–97.PubMedCrossRefGoogle Scholar
  9. 9.
    Todd, J., Armon, C., Griggs, A., Poole, S., & Berman, S. (2006). Increased rates of morbidity, mortality, and charges for hospitalized children with public or no health insurance as compared with children with private insurance in Colorado and the United States. Pediatrics, 118(2), 577–585.PubMedCrossRefGoogle Scholar
  10. 10.
    Chaudron, L. H., Szilagyi, P. G., Kitzman, H. J., Wadkins, H. I. M., & Conwell, Y. (2004). Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics, 113(3 Pt 1), 551–558.PubMedCrossRefGoogle Scholar
  11. 11.
    DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2009). U.S. census bureau, current population reports, P60–236, income, poverty, and health insurance coverage in the United States: 2008. Washington, DC: U.S. Government Printing Office.Google Scholar
  12. 12.
    Mandl, K. D., Tronick, E. Z., Brennan, T. A., Alpert, H. R., & Homer, C. J. (1999). Infant health care use and maternal depression. Archives of Pediatrics and Adolescent Medicine, 153(8), 808–813.PubMedGoogle Scholar
  13. 13.
    Phelan, K., Khoury, J., Atherton, H., & Kahn, R. S. (2007). Maternal depression, child behavior, and injury. Injury Prevention, 13(6), 403–408.PubMedCrossRefGoogle Scholar
  14. 14.
    Poehlmann, J., Schwichtenberg, A. J., Bolt, D., & Dilworth-Bart, J. (2009). Predictors of depressive symptom trajectories in mothers of preterm or low birth weight infants. Journal of Family Psychology, 23(5), 690–704.PubMedCrossRefGoogle Scholar
  15. 15.
    Guttmann, A., Dick, P., & To, T. (2004). Infant hospitalization and maternal depression, poverty and single parenthood—a population-based study. Child: Care, Health and Development, 30(1), 67–75.CrossRefGoogle Scholar
  16. 16.
    Bartlett, S. J., Kolodner, K., Butz, A. M., Eggleston, P., Malveaux, F. J., & Rand, C. S. (2001). Maternal depressive symptoms and emergency department use among inner-city children with asthma. Archives of Pediatrics and Adolescent Medicine, 155(3), 347–353.PubMedGoogle Scholar
  17. 17.
    Logan, J. E., Riley, A. W., & Barker, L. E. (2008). Parental mental and pain-related health and pediatric ambulatory care sensitive emergency department visits and hospitalizations. Health Services Research, 43(2), 656–674.PubMedCrossRefGoogle Scholar
  18. 18.
    Janicke, D. M., & Finney, J. W. (2003). Children’s primary health care services: Social-cognitive factors related to utilization. Journal of Pediatric Psychology, 28(8), 547–557.PubMedCrossRefGoogle Scholar
  19. 19.
    Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W.H. Freeman and Company.Google Scholar
  20. 20.
    Maddux, J. E., & Meier, L. J. (1995). Self-Efficacy and depression. In J. E. Maddux (Ed.), Self-Efficacy, adaptation, and adjustment: Theory, research, and application (pp. 143–169). New York: Plenum Press.Google Scholar
  21. 21.
    Howell, E., Mora, P., Dibonaventura, M., & Leventhal, H. (2009). Modifiable factors associated with changes in postpartum depressive symptoms. Archives of Women’s Mental Health, 12(2), 113.PubMedCrossRefGoogle Scholar
  22. 22.
    Teti, D. M., & Gelfand, D. M. (1991). Behavioral competence among mothers of infants in the first year: The mediational role of maternal self-efficacy. Child Development, 62(5), 918–929.PubMedCrossRefGoogle Scholar
  23. 23.
    Butterworth, P., Rodgers, B., & Windsor, T. D. (2009). Financial hardship, socio-economic position and depression: Results from the PATH through life survey. Social Science and Medicine, 69(2), 229–237.PubMedCrossRefGoogle Scholar
  24. 24.
    Bjelland, I., Krokstad, S., Mykletun, A., Dahl, A. A., Tell, G. S., & Tambs, K. (2008). Does a higher educational level protect against anxiety and depression? The HUNT study. Social Science and Medicine, 66(6), 1334–1345.PubMedCrossRefGoogle Scholar
  25. 25.
    Matheson, F. I., Moineddin, R., Dunn, J. R., Creatore, M. I., Gozdyra, P., & Glazier, R. H. (2006). Urban neighborhoods, chronic stress, gender and depression. Social Science and Medicine, 63(10), 2604–2616.PubMedCrossRefGoogle Scholar
  26. 26.
    Chaudron, L. H., Kitzman, H. J., Szilagyi, P. G., Sidora-Arcoleo, K., & Anson, E. (2006). Changes in maternal depressive symptoms across the postpartum year at well child care visits. Ambulatory Pediatrics, 6(4), 221–224.PubMedCrossRefGoogle Scholar
  27. 27.
    Reis, J. (1989). The structure of depression in community based young adolescent, older adolescent and adult mothers. Family Relations, 38(2), 164–168.CrossRefGoogle Scholar
  28. 28.
    Schempf, A. H., Minkovitz, C. S., Strobino, D. M., & Guyer, B. (2007). Parental satisfaction with early pediatric care and immunization of young children—The mediating role of age-appropriate well-child care utilization. Archives of Pediatrics and Adolescent Medicine, 161(1), 50–56.PubMedCrossRefGoogle Scholar
  29. 29.
    Schuster, M. A., Wood, D. L., Duan, N. H., Mazel, R. M., Sherbourne, C. D., & Halfon, N. (1998). Utilization of well-child care services for African-American infants in a low-income community: Results of a randomized, controlled case management home visitation intervention. Pediatrics, 101(6), 999–1005.PubMedCrossRefGoogle Scholar
  30. 30.
    Grus, C. L., Lopez-Hernandez, C., Delamater, A., Appelgate, B., Brito, A., Wurm, G., et al. (2001). Parental self-efficacy and morbidity in pediatric asthma. Journal of Asthma, 38(1), 99–106.PubMedCrossRefGoogle Scholar
  31. 31.
    Silver, E. J., Heneghan, A. M., Bauman, L. J., & Stein, R. E. (2006). The relationship of depressive symptoms to parenting competence and social support in inner-city mothers of young children. Maternal and Child Health Journal, 10(1), 105–112.PubMedCrossRefGoogle Scholar
  32. 32.
    Newman, R. D., Grupp-Phelan, J., Shay, D. K., & Davis, R. L. (1999). Perinatal risk factors for infant hospitalization with viral gastroenteritis. Pediatrics, 103(1), e3.PubMedCrossRefGoogle Scholar
  33. 33.
    Dennehy, P. H., Cortese, M. M., Begue, R. E., Jaeger, J. L., Roberts, N. E., Zhang, R., et al. (2006). A case-control study to determine risk factors for hospitalization for rotavirus gastroenteritis in U.S. children. Pediatric Infectious Disease Journal, 25(12), 1123–1131.PubMedCrossRefGoogle Scholar
  34. 34.
    Escobar, G. J., Greene, J. D., Hulac, P., Kincannon, E., Bischoff, K., Gardner, M. N., et al. (2005). Rehospitalization after birth hospitalisation: patterns among infants of all gestations. Archives of Disease in Childhood, 90(2), 125–131.PubMedCrossRefGoogle Scholar
  35. 35.
    Flynn, H. A., Davis, M., Marcus, S. M., Cunningham, R., & Blow, F. C. (2004). Rates of maternal depression in pediatric emergency department and relationship to child service utilization. General Hospital Psychiatry, 26(4), 316–322.PubMedCrossRefGoogle Scholar
  36. 36.
    Sadler, L. S., & Clemmens, D. A. (2004). Ambivalent grandmothers raising teen daughters and their babies. Journal of Family Nursing, 10(2), 211–231.CrossRefGoogle Scholar
  37. 37.
    Kitzman, H., Olds, D. L., Henderson, C. R., Jr., Hanks, C., Cole, R., Tatelbaum, R., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. A randomized controlled trial. JAMA, 278(8), 644–652.PubMedCrossRefGoogle Scholar
  38. 38.
    Black, M. M., Papas, M. A., Hussey, J. M., Hunter, W., Dubowitz, H., Kotch, J. B., et al. (2002). Behavior and development of preschool children born to adolescent mothers: Risk and 3-generation households. Pediatrics, 109(4), 573–580.PubMedCrossRefGoogle Scholar
  39. 39.
    Bennefield, R., & Bonnette, R. (2003). Structural and occupancy characteristics of housing: 2000. Retrieved from
  40. 40.
    Friedman, B., Heisel, M., & Delavan, R. (2005). Validity of the SF-36 five-item mental health index for major depression in functionally impaired, community-dwelling elderly patients. Journal of the American Geriatrics Society, 53(11), 1978–1985.PubMedCrossRefGoogle Scholar
  41. 41.
    Ostroff, J. S., Woolverton, K. S., Berry, C., & Lesko, L. M. (1996). Use of the mental health inventory with adolescents: A secondary analysis of the rand health insurance study. Psychological Assessment, 8(1), 105–107.CrossRefGoogle Scholar
  42. 42.
    Rumpf, H. J., Meyer, C., Hapke, U., & John, U. (2001). Screening for mental health: Validity of the MHI-5 using DSM-IV axis I psychiatric disorders as gold standard. Psychiatry Research, 105(3), 243–253.PubMedCrossRefGoogle Scholar
  43. 43.
    Evans, G. W., Ricciuti, H. N., Hope, S., Schoon, I., Bradley, R. H., Corwyn, R. F., et al. (2010). Crowding and Cognitive Development: The mediating role of maternal responsiveness among 36-month-old children. Environment and Behavior, 42(1), 135–148.CrossRefGoogle Scholar
  44. 44.
    Anderson, L. N., Campbell, M. K., daSilva, O., Freeman, T., & Xie, B. (2008). Effect of maternal depression and anxiety on use of health services for infants. Canadian Family Physician, 54(12), 1718–17195.PubMedGoogle Scholar
  45. 45.
    Perrin, J. M., Kuhlthau, K. A., Gortmaker, S. L., Beal, A. C., & Ferris, T. G. (2002). Generalist and subspecialist care of children with chronic conditions. Ambulatory Pediatrics, 2(6), 462–469.PubMedCrossRefGoogle Scholar
  46. 46.
    Royston, P. (2005). Multiple imputation of missing values: Update of ice. The State Journal, 5(4), 527–536.Google Scholar
  47. 47.
    Barnes, C. R., & Adamson-Macedo, E. N. (2007). Perceived maternal parenting self-efficacy (PMP S-E) tool: Development and validation with mothers of hospitalized preterm neonates. Journal of Advanced Nursing, 60(5), 550–560.PubMedCrossRefGoogle Scholar
  48. 48.
    Maddux, J. E., & Lewis, J. (1995). Self-Efficacy and adjustment. In J. E. Maddux (Ed.), Self-efficacy, adaptation, and adjustment: Theory, research, and application (pp. 37–68). New York: Plenum Press.Google Scholar
  49. 49.
    Gross, D., Garvey, C., Julion, W., Fogg, L., Tucker, S., & Mokros, H. (2009). Efficacy of the Chicago parent program with low-income African American and Latino parents of young children. Prevention Science, 10(1), 54–65.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Margaret L. Holland
    • 1
    • 2
  • Byung-Kwang Yoo
    • 3
  • Harriet Kitzman
    • 2
  • Linda Chaudron
    • 4
  • Peter G. Szilagyi
    • 1
  • Helena Temkin-Greener
    • 3
  1. 1.Department of PediatricsUniversity of Rochester School of Medicine and DentistryRochesterUSA
  2. 2.School of NursingUniversity of Rochester School of Medicine and DentistryRochesterUSA
  3. 3.Department of Community and Preventive MedicineUniversity of Rochester School of Medicine and DentistryRochesterUSA
  4. 4.Department of PsychiatryUniversity of Rochester School of Medicine and DentistryRochesterUSA

Personalised recommendations