Racial and Ethnic Disparities in the Knowledge of

Racial and Ethnic Disparities in the Knowledge of Shaken Baby Syndrome among Recent Mothers Findings from the 2004 -2008 Rhode Island PRAMS Hanna Kim, Samara Viner-Brown, Rachel Cain Center for Health Data and Analysis Rhode Island Department of Health

Background • Shaken Baby Syndrome (SBS) is a form of child abuse that can result in permanent brain damage or death. • SBS usually occurs when a parent or caregiver violently shakes a baby or toddler due to frustration or anger. • If a baby is forcefully shaken, his or her fragile brain moves back and forth inside the skull, which causes bruising, swelling and bleeding.

Background • Serious injuries associated with SBS may include blindness or eye injuries, brain damage, damage to the spinal cord, and delay in normal development. • In 2001, 903, 000 children suffered from SBS in the U. S. and an additional 1, 300 died from it. • About 20% of cases are fatal in the first few days after injury, and the majority of the survivors are left with disabilities.

Shaken Baby Syndrome Source: Healthline website: http: //www. healthline. com/galecontent/shaken-baby-syndrome-2

Shaken Baby Syndrome Source: The National Center on SBS website

Study Questions • What is the prevalence of Lack of Knowledge of Shaken Baby Syndrome (LKSBS) among Rhode Island recent mothers? • Are there any Racial and Ethnic Disparities in the LKSBS? • How does the Immigrant Status interact across race/ethnicity in the LKSBS?

Methods • Data Source: 2004 -2008 RI Pregnancy Risk Assessment Monitoring System (PRAMS) Total Respondents for 5 years: 6, 959 – Weighted Response Rate (5 -year average): 73. 2% – Average PRAMS population per year: 11, 816 – Year PRAMS Pop. Respondents Weighted R. R. 2004 12, 064 1, 506 75. 5 2005 12, 013 1, 424 75. 1 2006 11, 732 1, 360 72. 5 2007 11802 1, 372 72. 1 2008 11, 467 1, 297 70. 4

What is the PRAMS? (Pregnancy Risk Assessment Monitoring System) • A surveillance project of the CDC and state Health Departments to monitor the health of mothers and infants. • Collects state specific, population based data on maternal behaviors and experiences before, during, and after pregnancy. • A sample survey of recent mothers and administered 2 5 months after baby’s delivery by mail or telephone. • The PRAMS sample is chosen from all women who had a live birth recently.

Variables Used Outcome Variable: • Lack of Knowledge of SBS (LKSBS): “No” to the question “Have you ever heard or read about what can happen if a baby is shaken? ” Exposure Variables: • Race/Ethnicity: NH White NH Black NH Asian/PI Hispanic • Immigrant Status: Non Immigrant (US born) Immigrant (Foreign born) Confounders: Maternal Age, Education, Income, Marital Status, and Parity

Statistical Analysis • Chi square tests for bivariate relationships between socio demographic factors and LKSBS. • Multivariable logistic regression analyses to determine independent and joint effects of race/ethnicity and immigrant status on LKSBS. • SUDAAN (Survey Data Analysis) v 10 software was used for statistical analyses to account for complex sample design of the survey.

Results

Rhode Island PRAMS Population Distribution (2004 -2008) • Race/Ethnicity – NH White: 66% – NH Black : 9% – NH Asian/PI : 4% – Hispanic: 20% – NH Others, including AI: 1% (excluded) • Immigrant Status – Immigrant: 25% – Non Immigrant: 75%

Rhode Island PRAMS Population Distribution (2004 -2008) Proportion of Immigrant by Race/Ethnicity – – NH White: 5% NH Black : 48% NH Asian/PI : 69% Hispanic: 72% Minority groups have higher proportion of immigrant

Prevalence of LKSBS: Bivariate Analysis • • Year (2004 2008) Race/Ethnicity Immigrant Status Maternal Age Education Household Income Marital Status Parity Exposure Vars. Confounding Vars.

Prevalence of LKSBS by Year, RI 2004 -08 P =. 6197

Prevalence of LKSBS by Race/Ethnicity P <. 0001

Prevalence of LKSBS by Immigrant Status P <. 0001

Prevalence of LKSBS by Maternal Age P <. 0001

Prevalence of LKSBS by Maternal Education P <. 0001

Prevalence of LKSBS by Household Income P <. 0001

Prevalence of LKSBS by Marital Status P <. 0001

Prevalence of LKSBS by Parity P = 0. 0040

Prevalence of LKSBS: Bivariate Analysis • The prevalence of LKSBS was significantly higher among NH Blacks (15. 8%), NH Asians (16. 7%), Hispanics (13. 6%), Immigrants (17. 1%), Teens (10. 5%), mothers with < High School Education (11. 2%), Incomes < $20, 000 (9. 8%), Unmarried (8. 8%), First Time (7. 2%) mothers.

Multivariable Logistic Regression • To determine the independent effects of race/ethnicity and immigrant status on LKSBS, while controlling for confounding factors (maternal age, education, income, marital status and parity). • To determine the joint effects of race/ethnicity and immigrant status on LKSBS, while controlling for confounding factors.

Assessing Independent Effects of Race/Ethnicity and Immigrant Status Outcome Variable: • Lack of Knowledge of SBS (LKSBS): Yes/No Exposure Variables: • Race/Ethnicity NH-White: Referent Group NH Black NH Asian/PI Hispanic • Immigrant Status Non-Immigrant: Referent Group Immigrant Confounders: Maternal Age, Education, Income, Marital Status, and Parity

Effects of Race/Ethnicity and Immigrant Status on LKSBS Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)* AOR 95% CI NH White NH Black NH Asian/PI Hispanic Ref 3. 1 3. 4 1. 8 Ref 2. 0 4. 8 2. 0 5. 8 1. 1 2. 8 Non Immigrant Ref 3. 9 Ref 2. 7 5. 6 * AORs and 95% CIs were calculated after controlling for maternal age, education, household income, marital status, and parity.

Effects of Race/Ethnicity on LKSBS: Stratified by Immigrant Status Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)* NH White NH Black NH Asian/PI Hispanic Non-Immigrants (n=5, 046) AOR (95% CI) Immigrants (n=1, 898) AOR (95% CI) Ref (1. 3 5. 2) (0. 7 7. 6) (1. 7 5. 6) Ref (1. 3 4. 9) (1. 4 5. 9) (0. 6 2. 1) 2. 6 2. 4 3. 1 2. 5 2. 9 1. 2 * AORs and 95% CIs were calculated after controlling for maternal age, education, household income, marital status, and parity.

Assessing Joint Effects of Race/Ethnicity and Immigrant Status Outcome Variable: • Lack of Knowledge of SBS (LKSBS): Yes/No Exposure Variables: • Race/Ethnicity and Immigrant Status - Non-Immigrant, NH-White: Referent Group - Non Immigrant, NH Black - Non Immigrant, NH Asian/PI - Non Immigrant, Hispanic - Immigrant, NH White - Immigrant, NH Black - Immigrant, NH Asian/PI - Immigrant, Hispanic Confounders: Maternal Age, Education, Income, Marital Status, and Parity

Joint Effects of Race/Ethnicity and Immigrant Status on LKSBS Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)* AOR Non Immigrant, NH White Non Immigrant, HN Black Non Immigrant, NH Asian/PI Non Immigrant, Hispanic Immigrant, NH White Immigrant, HN Black Immigrant, NH Asian/PI Immigrant, Hispanic Ref 2. 5 2. 3 3. 0 5. 0 13. 6 14. 7 6. 5 Indep. Effects: Either Minority OR Immigrant Joint Effects: Both Minority AND Immigrant * AORs and 95% CIs were calculated after controlling for maternal age, education, household income, marital status, and parity. 95% CI Ref 1. 3 4. 9 0. 7 7. 4 1. 7 5. 3 2. 8 9. 1 8. 5 21. 7 8. 5 25. 5 4. 4 9. 6

Assessing Interaction: Additive Scale • Joint Effects of NH-Back & Immigrant: – Expected Odds Ratio = 2. 5+5. 0 1. 0 = 6. 5 – Observed Odds Ratio = 13. 6 Positive Additive Interaction • Joint Effects of NH-Asian/PI & Immigrant: – Expected Odds Ratio = 2. 3+5. 0 1. 0 = 6. 3 – Observed Odds Ratio = 14. 7 Positive Additive Interaction • Joint Effects of Hispanic & Immigrant: – Expected Odds Ratio = 3. 0+5. 0 1. 0 =7. 0 – Observed Odds Ratio = 6. 5 No Additive Interaction

Assessing Interaction: Multiplicative Scale • Joint Effects of NH-Back & Immigrant: – Expected Odds Ratio = 2. 5*5. 0 = 12. 5 – Observed Odds Ratio = 13. 6 No Multiplicative Interaction • Joint Effects of NH-Asian/PI & Immigrant: – Expected Odds Ratio = 2. 3*5. 0 = 11. 5 – Observed Odds Ratio = 14. 7 Positive Multiplicative Interaction ? ? ? • Joint Effects of Hispanic & Immigrant: – Expected Odds Ratio = 3. 0*5. 0 = 15. 0 – Observed Odds Ratio = 6. 5 Negative Multiplicative Interaction

Conclusions • Overall, 6. 2% of RI recent mothers lacked a Knowledge of SBS, and the rate did not change during 2004 2008. • There were significant Racial and Ethnic Disparities in the LKSBS; the odds of LKSBS were significantly higher among NH Black, NH Asian/PI, and Hispanic mothers (vs. NH White).

Conclusions • There was an interaction between race/ethnicity and immigrant status in the LKSBS; being an Immigrant & Black, or being an Immigrant & Asian/PI had the strong positive (synergistic) additive joint effects. • A logistic regression model with joint effects fitted the data better than a model with independent effects only.

Limitations • Measurement Issue: – Knowledge SBS: level of knowledge – Length of Immigration • Sample Size Issue: – Small sample size for some race/ethnicity categories, e. g. non immigrant Asian/PI mothers (n<100)

Public Health Implications • Substantial proportions of RI minority women who recently gave birth are also immigrants. These women are at highest risk for LKSBS. • Public health efforts should target minority and immigrant mothers to educate them about the dangers of shaking a baby.

THANK YOU! Contact Information: Hanna Kim, Ph. D: Hanna. Kim@health. ri. gov