Skip to main content

Measuring the Developing Therapeutic Relationship Between Pregnant Women and Community Health Workers Over the Course of the Pregnancy in a Study Intervention


The Scale to Assess the Therapeutic Relationship in Community Mental Health Care (STAR) is a frequently-administered tool for measuring therapeutic relationships between clinicians and patients. This manuscript tested the STAR’s psychometric properties within a community health worker (CHW)-led intervention study involving pregnant and postpartum women. Women (n = 141) enrolled in the study completed the 12-item participant STAR survey (STAR-P) at two time points over the course of pregnancy and at two time points after delivery. The factor structure of the STAR-P proved to be unstable with this population. However, a revised 9-item STAR-P revealed a two-factor model of positive and negative interactions, and demonstrated strong internal consistency at postpartum time points. The revised STAR-P shows strong psychometric properties, and is suitable for use to evaluate the relationship developed between CHWs and pregnant and postpartum women in an intervention program.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. 1.

    Braun, R., Catalani, C., Wimbush, J., & Israelski, D. (2013). Community health workers and mobile technology: A systematic review of the literature. PloS One, 8(6), e65772. doi:10.1371/journal.pone.0065772.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98(2), 310.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Collins, N. L., Dunkel-Schetter, C., Lobel, M., & Scrimshaw, S. C. (1993). Social support in pregnancy: Psychosocial correlates of birth outcomes and postpartum depression. Journal of Personality and Social Psychology, 65(6), 1243.

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Comrey, A. L., & Lee, H. B. (2013). A first course in factor analysis. Psychology Press.

  5. 5.

    Dunkel-Schetter, C., Sagrestano, L. M., Feldman, P. A., & Killingsworth, C. (1996). Social support and pregnancy. In Handbook of social support and the family (pp. 375–412). Springer US.

  6. 6.

    Feldman, P. J., Dunkel-Schetter, C., Sandman, C. A., & Wadhwa, P. D. (2000). Maternal social support predicts birth weight and fetal growth in human pregnancy. Psychosomatic Medicine, 62(5), 715–725.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Gairing, S. K., Jäger, M., Ketteler, D., Rössler, W., & Theodoridou, A. (2011). Evaluation of the German version of the STAR scale. Psychiatrische Praxis, 38(4), 178–184.

    Article  PubMed  Google Scholar 

  8. 8.

    Kvrgic, S., Beck, E.-M., Cavelti, M., Kossowsky, J., Stieglitz, R.-D., & Vauth, R. (2012). Focusing on the adult attachment style in schizophrenia in community mental health centres: Validation of the Psychosis Attachment Measure (PAM) in a German-speaking sample. International Journal of Social Psychiatry, 58(4), 362–373.

    Article  PubMed  Google Scholar 

  9. 9.

    Lichtveld, M. Y., & Arosemena, F. A. (2014). Resilience in the Aftermath of the Gulf of Mexico Oil Spill: An Academic-Community Partnership to Improve Health Education, Social Support, Access to Care, and Disaster Preparedness. Paper presented at the International Oil Spill Conference Proceedings.

  10. 10.

    Loos, S., Kilian, R., Becker, T., Janssen, B., Freyberger, H., Spiessl, H., et al. (2015). Psychometric properties of the German version of the scale to assess the therapeutic relationship in community mental health care (D-STAR). European Journal of Psychological Assessment, 28(4), 255–261.

    Article  Google Scholar 

  11. 11.

    Mcguire-Snieckus, R., McCABE, R., Catty, J., Hansson, L., & Priebe, S. (2007). A new scale to assess the therapeutic relationship in community mental health care: STAR. Psychological Medicine, 37(01), 85–95.

    Article  PubMed  Google Scholar 

  12. 12.

    Nemcek, M. A., & Sabatier, R. (2003). State of evaluation: community health workers. Public Health Nursing, 20(4), 260–270.

    Article  PubMed  Google Scholar 

  13. 13.

    Norbeck, J. S., & Anderson, N. J. (1989). Psychosocial predictors of pregnancy outcomes in low-income black, Hispanic, and white women. Nursing Research, 38(4), 204–209.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Norris, S. L., Chowdhury, F. M., Van Le, K., Horsley, T., Brownstein, J. N., Zhang, X., & Satterfield, D. W. (2006). Effectiveness of community health workers in the care of persons with diabetes. Diabetic Medicine, 23(5), 544–556.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Nunnally, J. C., Bernstein, I. H., & Berge, J. M. T. (1967). Psychometric theory (Vol. 226). New York: McGraw-Hill.

    Google Scholar 

  16. 16.

    O’hara, M. W., & Swain, A. M. (1996). Rates and risk of postpartum depression-a meta-analysis. International Review of Psychiatry, 8(1), 37–54.

    Article  Google Scholar 

  17. 17.

    Park, S. G., Derman, M., Dixon, L. B., Brown, C. H., Klingaman, E. A., Fang, L. J., et al. (2014). Factors associated with shared decision-making preferences among veterans with serious mental illness. Psychiatric Services, 65(12), 1409–1413.

    Article  PubMed  Google Scholar 

  18. 18.

    Roman, L. A., Gardiner, J. C., Lindsay, J. K., Moore, J. S., Luo, Z., Baer, L. J., & Fitzgerald, H. E. (2009). Alleviating perinatal depressive symptoms and stress: A nurse-community health worker randomized trial. Archives of Women’s Mental Health, 12(6), 379–391.

    Article  PubMed  Google Scholar 

  19. 19.

    Roman, L. A., Raffo, J. E., & Meghea, C. I. (2012). Maternal perceptions of help from home visits by Nurse-Community Health Worker Teams. American Journal of Public Health, 102(4), 643–645.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Rugkåsa, J., Molodynski, A., Yeeles, K., Vazquez Montes, M., Visser, C., & Burns, T. (2015). Community treatment orders: Clinical and social outcomes, and a subgroup analysis from the OCTET RCT. Acta Psychiatrica Scandinavica, 131(5), 321–329.

    Article  PubMed  Google Scholar 

  21. 21.

    Scheppers, E., Van Dongen, E., Dekker, J., Geertzen, J., & Dekker, J. (2006). Potential barriers to the use of health services among ethnic minorities: A review. Family Practice, 23(3), 325–348.

    Article  PubMed  Google Scholar 

  22. 22.

    Slusser, W. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. AAP Grand Rounds, 18(2), 15–16.

    Article  Google Scholar 

  23. 23.

    Spielberger, C. D., & Gorsuch, R. L. (1983). State-trait anxiety inventory for adults: Manual, instrument, and scoring guide. Menlo Park: Mind Garden, Incorporated.

    Google Scholar 

  24. 24.

    Suhr, D. D. (2005). Principal component analysis vs. exploratory factor analysis. Paper presented at the SUGI 30 Proceedings.

  25. 25.

    Theodoridou, A., Schlatter, F., Ajdacic, V., Rössler, W., & Jäger, M. (2012). Therapeutic relationship in the context of perceived coercion in a psychiatric population. Psychiatry Research, 200(2), 939–944.

    Article  PubMed  Google Scholar 

  26. 26.

    Truxillo, C. (2008). Multivariate statistical methods: Practical research applications. Cary, NC: SAS Institute Inc.

    Google Scholar 

  27. 27.

    Viswanathan, M., Kraschnewski, J. L., Nishikawa, B., Morgan, L. C., Honeycutt, A. A., Thieda, P., & Jonas, D. E. (2010). Outcomes and costs of community health worker interventions: A systematic review. Medical Care, 48(9), 792–808.

    Article  PubMed  Google Scholar 

  28. 28.

    Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. doi:10.1037/0022-3514.54.6.1063.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Whitley, E. M., Everhart, R. M., & Wright, R. A. (2006). Measuring return on investment of outreach by community health workers. Journal of Health Care for the Poor and Underserved, 17(1), 6–15.

    Article  PubMed  Google Scholar 

  30. 30.

    Wittorf, A., Jakobi, U. E., Bannert, K. K., Bechdolf, A., Müller, B. W., Sartory, G., & Herrlich, J. (2010). Does the cognitive dispute of psychotic symptoms do harm to the therapeutic alliance? The Journal of Nervous and Mental Disease, 198(7), 478–485.

    Article  PubMed  Google Scholar 

  31. 31.

    Women, Infants and Children: WIC Eligibility Requirements. (2015). Retrieved April 29, 2015, from

Download references


This research was supported by the National Institutes of Health under Grant Number 5U19ES020677. The authors thanks to the CHWs Starleen Maharaj-Lewis, Christine Dennis, Onita Harris, Courtney Schultheis, Patricia Davis, and Kimisha Sawyer for their commitment to the study subjects and aiding in data collection. Special thanks to Farah Arosemena and Dr. Hannah Covert, for their guidance and expertise during the design and implementation of the study.


This study was funded by the National Institutes of Health (5U19ES020677).

Author information



Corresponding author

Correspondence to Chris Mundorf.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lichtveld, M.Y., Shankar, A., Mundorf, C. et al. Measuring the Developing Therapeutic Relationship Between Pregnant Women and Community Health Workers Over the Course of the Pregnancy in a Study Intervention. J Community Health 41, 1167–1176 (2016).

Download citation


  • STAR
  • Community health worker
  • Pregnancy
  • Psychometric scale adaptation
  • Exploratory factor analysis