Public Health Nursing Vol. 17 No. 4, pp.

280–291
0737-1209/00/$15.00
q Blackwell Science, Inc.

Social Support and

Psychological Functioning
Among High-Risk Mothers:
The Impact of the Baby Love
Maternal Outreach
Worker Program
Maryam Navaie-Waliser, Dr.P.H.,
Sandra L. Martin, Ph.D.,
Irene Tessaro, R.N., Dr.P.H.,
Marci K. Campbell, R.D., Ph.D., and
Alan W. Cross, M.D.

self-esteem (p 4 0.039) and were less depressed (p 4 0.015).

Abstract This study compared two groups of high-risk
Medicaid-eligible mothers, 221 who participated in a maternal
home visitation program and 198 who did not, to determine
whether program participation was associated with improvements
in the mothers’ psychological functioning 1 year after delivery,
and whether these improvements were associated with the type
and intensity of support provided by home visitors. The results
suggest that, compared to nonparticipants, participants provided
with more intensive home visitor support had significantly higher
Maryam Navaie-Waliser is a Research Associate, Center for
Home Care Policy and Research, Visiting Nurse Service of New
York, New York, New York. Sandra L. Martin is an Associate
Professor, Department of Maternal and Child Health, University
of North Carolina, Chapel Hill, North Carolina. Irene Tessaro
is an Assistant Professor, Department of Community Medicine
and Health Promotion, West Virginia University, Morgantown,
West Virginia. Marci K. Campbell is an Assistant Professor, De-
partment of Nutrition, University of North Carolina, Chapel Hill,
North Carolina. Alan W. Cross is Professor and Chair, Center for
Health Promotion and Disease Prevention, University of North
Carolina, Chapel Hill, North Carolina.
Address correspondence to Maryam Navaie-Waliser, Center
for Home Care Policy and Research, Visiting Nurse Service of
New York, 5 Penn Plaza, 18th Floor, New York, NY 10001–1810.
E-mail: mnavaie@vnsny.org
Participants with less intensive home visitor support, however,
did not differ significantly from nonparticipants in their self-
esteem or depression levels. No significant differences were ob-
served in the perceived stress levels of participants as compared
with nonparticipants, regardless of the intensity of home visitor
support. Mothers who had support from the baby’s father, how-
ever, had significantly lower perceived stress levels than mothers
with no support from the baby’s father (p 4 0.046). Moreover,
the type of support provided by home visitors (emotional, instru-
mental, informational) did not appear to be related to the mothers’
psychological functioning. This study suggests that the intensity
of support is an important component of maternal home visitation
programs that aim to improve women’s psychological
functioning.
Key words: social support, depression, pregnancy, Medicaid,
home visitation, informal care, self-esteem, mental health, psy-
chological functioning.
INTRODUCTION
One of the most frequently cited, but understudied, risk
factors for impaired psychological health is lack of
adequate social support (Brown, Gray, Greene, & Milb-

280
 Navaie-Waliser et al.: Social Support and Psychological Functioning 281
urn, 1992; Collins, Dunkel-Schetter, Lobel, & Scrimshaw,
1993; Gjerdingen & Chaloner, 1994; Jung, 1997). In an
effort to alleviate this risk factor, maternal home visitation
programs have been implemented in targeted communities
across the nation to provide social support services. The
foundation of most maternal home visitation programs
rests on social support theory (Norbeck, 1981; Langford,
Bowsher, Maloney, & Lillis, 1997) which emphasizes
the important links between receiving emotional (for
example, esteem, counseling, empathizing), instrumental
(for example, assistance with transportation, childcare,
service linkage), and informational (for example, health
education) social support and having good psychological
health. Social support theory also distinguishes between
two types of support: informal (that is, support provided
by relatives and friends) and formal (that is, support
provided by health professionals such as doctors, nurses,
and home visitors) (Cutrona & Russell, 1990).
To date, consensus has not been reached as to the
precise mechanisms by which informal and formal social
support affect psychological health. Nevertheless, many
have suggested that social support helps to increase
coping skills, self-esteem, self-control and self-confidence
(Cohen, Hettler, & Park, 1997; Warren, 1997), and to
reduce depression (Collins et al., 1993; Seguin, Potvin,
St. Dennis, & Loiselle, 1995; Barnet, Joffe, Duggan, &
Wilson, 1996) and perceived stress (Cohen & Willis,
1985; Krause, 1986, 1987; Hoffman & Hatch, 1993).
Although one of the key objectives of many maternal
home visitation programs is to improve their participants’
psychological functioning, a very limited number of
evaluations have assessed the impact of these programs
with respect to this outcome. Among published studies
that have investigated the association between formal
social support provided by home visitors and women’s
psychological functioning (Olds, Henderson, Tatel-
baum, & Chamberlin, 1986; Oakley, Rajan, & Grant,
1990; Marcenko & Spence, 1994; Kitzman et al., 1997),
the majority have not considered a comprehensive set
of constructs to assess psychological functioning. Further-
more, none has adjusted for the potential effects of social
support from sources other than home visitors, and
none has adequately determined which components of
programmatic support may be associated with women’s
psychological functioning.
The purpose of this investigation was to evaluate a
North Carolina (NC) maternal home visitation program
to determine: (1) whether participation in the program
was associated with improvements in the mothers’ psy-
chological functioning, taking into consideration the ef-
fects of social support from sources other than home
visitors; and (2) whether improvements in the mothers’
psychological functioning were associated with the type
and intensity of support provided by home visitors.
METHODS
The Baby Love Maternal Outreach Worker (MOW)
Program
NC’s overall infant mortality rate (IMR) has long been
among the worst in the nation, with mortality rates twice
as high among African American infants (15.0) as com-
pared to white infants (6.8) (State Center for Health and
Environmental Studies, Department of Environment,
Health, and Natural Resources, 1995). In 1992, in an effort
to address NC’s high IMR, the Baby Love MOW Program
was launched in 24 counties across the state to target
Medicaid-eligible mothers and infants. The program was
patterned after the home visitor, ‘‘natural helpers,’’ com-
munity-based social support model of South Carolina’s
Resource Mothers Program (Heins, Nancy, & Ferguson,
1987) and NC’s Helping Mothers and Helping Families
programs (Cross & McGloin, 1992).
The MOW program is a prenatal home visitation social
support intervention which employs community health ad-
vocates as paraprofessional MOWs. MOWs receive ap-
proximately 60 hours of training on the following topics:
(1) home visitation techniques; (2) transportation needs
assessment; (3) maternal and child health education; (4)
assessments of the living situations of program clients; (5)
assisting program clients with the identification of and
access to appropriate services; (6) skills development in
the areas of relationship building, communication, problem
solving, and emotional and family support; (7) making
referrals for needed services; and (8) advocacy. Each MOW
works with a maximum caseload of 25 to 30 families
annually.
Through home visits, the MOWs encourage the use of
preventive health services, foster healthy behaviors, help
improve parenting skills, and enhance psychological
health. In general, program services begin prior to 28
weeks’ gestation and continue on a monthly basis (or more
often based on familial needs as assessed by the MOWs)
through the infant’s 1st birthday. Health departments and
publicly funded community health centers make referrals
to the program on the basis of social and/or geographical
isolation, young maternal age (that is, adolescent preg-
nancy), reported or suspected substance use, family vio-
lence, and unstable housing.
Study Design and Sample
This research was undertaken as part of a comprehensive
longitudinal evaluation of the MOW program (Tessaro et
al., 1997). This phase of the program’s evaluation was
282 Public Health Nursing Volume 17 Number 4 July/August 2000
conducted in two steps. First, 18 counties (nine with MOW
services and nine without) were selected based on: (1) a
3-hour driving proximity to the university that housed the
evaluation team; and (2) their comparability with one an-
other in the proportion of births to African American moth-
ers, births to teenage mothers (17 years or younger),
preterm births, low birthweight infants, and births to moth-
ers who lived in rural areas.
Second, a study sample of pregnant women was selected
from these 18 counties by obtaining referrals from the
maternity care coordinators who oversaw the women’s care
in each county. To achieve comparability between the two
groups, the maternity care coordinators in the comparison
counties referred women to this phase of the evaluation if
they would have linked the women to the MOW program
had the program been available in their counties. The ma-
ternity care coordinators used the following screening crite-
ria for referrals: (1) women who were reported as less than
28 weeks’ pregnant; and (2) women with at least one of
the following risk factors present: noncompliance of care,
previous poor birth outcome (for example, low birthweight
infant), adolescent pregnancy, transportation difficulties,
inadequate or no social support, high medical risk, physical
and/or substance abuse, mental illness, lack of housing or
other stressful family situations.
Through this two step process, 705 pregnant women
were identified, all of whom agreed to participate in this
phase of the MOW program evaluation. Of this group, 373
women were from MOW counties and 332 were from
comparison counties. Attempts were made to follow and
interview all of the women longitudinally from pregnancy
until their infant’s 1st birthday. One year after delivery,
however, it was possible to conduct interviews with only
246 (66%) MOW program participants and 198 (60%)
nonparticipants (mothers from the comparison counties).
Given the main objective of this study, namely to determine
the impact of the MOW program on mothers’ psychological
functioning 1 year after delivery, the 246 MOW program
participants were asked, around the time of their infant’s
1st birthday, how long they participated in the program.
Two hundred twenty-one of the mothers reported receiving
program services for at least 10 months after delivery.
Thus, for the purpose of these analyses, the study sample
was dichotomized into two groups: MOW program partici-
pants who received home visits for at least 10 months after
delivery (n 4 221) and a comparable group of nonpartici-
pant mothers who received no MOW services (n 4 198).
Data Collection and Assessment
Between 1992 and 1995, data were collected using struc-
tured, face-to-face interviews conducted with MOW pro-
gram participants and nonparticipants in their homes during
pregnancy and approximately 1 year after delivery. The
interviews were conducted by 28 trained interviewers and
were between 45 and 90 minutes in duration. Data were
collected on a wide range of topics including the mother’s:
(1) sociodemographic characteristics (for example, age,
race, marital status, education level, annual family income
from all sources, and employment status), (2) informal
social support (that is, support provided by relatives and
friends), (3) formal social support (that is, support provided
by health professionals), and (4) psychological functioning
(that is, self-esteem, perceived stress, and depression).
Data regarding the mothers’ informal and formal social
support included information on the sources and intensity
of support. Informal sources of support included the preg-
nant woman’s mother, the baby’s father, other relatives
(that is, relatives other than the pregnant woman’s mother
or the baby’s father), and friends. Formal sources of support
included the MOW program’s home visitors, physicians,
and nurses. For each source of support, responses to ques-
tions were coded dichotomously (yes/no). Data on the in-
tensity of social support from informal and formal sources
were collected using a 4-point Likert scale that ranged
from support provided ‘‘almost never’’ to ‘‘very often.’’
For the purposes of analyses, results from this scale were
dichotomized as ‘‘less intensive support’’ if home visits
were provided almost never or sometimes and ‘‘more inten-
sive support’’ if home visits were provided fairly or very
often.
Additional data regarding the type of social support
provided by home visitors were collected from mothers
who participated in the MOW program and were catego-
rized as emotional (for example, esteem building, counsel-
ing), instrumental (for example, assistance with
transportation, childcare, and service linkage), and infor-
mational (for example, health education) (Pierce, Sarason,
Sarason, Joseph, & Henderson, 1996). Informational sup-
port was further stratified according to the following
subject matters: nutrition, infant care, and family plan-
ning. For each type of support, data were coded dichoto-
mously (yes/no).
Psychological functioning was assessed by three pre-
viously validated and reliable psychological instruments.
Self-esteem was measured by the Rosenberg Self-Esteem
Scale (RSE) (Rosenberg, 1981) which has been used in
a wide range of populations, including pregnant and
postpartum women (Marcenko & Spence, 1994; Norbeck,
DeJoseph, & Smith, 1996; Copper et al., 1996; Warren,
1997). The RSE has a coefficient of reproducibility of
0.92, a coefficient of scalability of 0.72, and a test-retest
reliability which ranges from r 4 0.85 to r 4 0.88
(Rosenberg, 1979). RSE scores are continuous measures,
with higher scores indicating higher levels of self-esteem.
 Navaie-Waliser et al.: Social Support and Psychological Functioning 283
Perceived stress was measured by the Perceived Stress
Scale (PSS) (Cohen, Kamarck, & Mermelstein, 1983)
which also has been used in studies of pregnant women
(Collins et al., 1993; Wadhwa, Sandman, Porto, Dunkel-
Schetter, & Garite, 1993). The PSS has a coefficient
alpha reliability of 0.85 and a test-retest correlation of
0.85 (Copper et al., 1996). PSS scores are continuous
measures, with higher scores indicating higher levels of
perceived stress. Depression was measured by the Center
for Epidemiologic Studies Depression Scale (CES-D)
(Radloff, 1977) which has been widely used in both
pregnant (Zuckerman, Bauchner, Parker, & Cabral, 1990)
and postpartum women (Logsdon, 1994). Content, con-
current, and discriminant validity of the CES-D have
been demonstrated (Radloff, 1977; McDowell & Newell,
1996) along with high internal consistency and reliability
(Brown et al., 1992; Logsdon, 1994). CES-D scores are
continuous measures, with higher scores indicating higher
levels of depression.
Statistical Analyses
Descriptive statistics (for example, frequencies, means, and
standard deviations) and bivariate analyses (for example,
the Cochran Mantel-Haenszel Chi-Square test, unadjusted
odds ratios, 95% confidence intervals, Student’s t test,
and p-values) were used to compare the sociodemographic
characteristics, informal and formal social support, and
psychological functioning of the MOW program partici-
pants and nonparticipants. Among mothers who partici-
pated in the MOW program, descriptive statistics also were
used to examine the associations between the type and
intensity of social support provided by home visitors and
the mothers’ psychological functioning.
Multivariate analyses were performed using linear re-
gression techniques with the aid of the Statistical Analysis
System software program (SAS Institute, 1996). The linear
regression models examined self-esteem, perceived stress,
and depression (that is, psychological functioning) 1 year
after delivery as a function of the intensity of MOW pro-
gram participation (no participation in the MOW program,
MOW program participation with less intensive home visi-
tor support, or MOW program participation with more
intensive home visitor support), adjusting for sources of
informal and formal support, baseline psychological func-
tioning levels, age, race, and marital status. Additional
linear regression analyses were conducted to test for associ-
ations between the mothers’ psychological functioning lev-
els 1 year after delivery, the type of support provided by
home visitors (that is, emotional, instrumental, informa-
tional), and the intensity of support from relatives and
friends, adjusting for potential confounders.
RESULTS
Descriptive Analyses
Sociodemographic Characteristics
Crude (unadjusted) analyses revealed significant differ-
ences in the sociodemographic characteristics of MOW
program participants and nonparticipants (Table 1). Com-
pared to nonparticipants, mothers in the MOW program
were more likely to be younger (OR 4 1.5, 95% CI 4
1.0, 2.2; p 4 0.049), African American (OR 4 1.6, 95%
CI 4 1.1, 2.5; p 4 0.020), unmarried (OR 4 2.0, 95%
CI 4 1.3, 3.3, p 4 0.003), of low education level (OR
4 2.5, 95% CI 4 1.7, 3.7; p 4 0.001), and of low income
(OR 4 2.3, 95% CI 4 1.4, 3.9; p 4 0.001). There was
no significant difference in the employment status of MOW
program participants and nonparticipants.
Informal and Formal Social Support
As shown in Table 2, crude (unadjusted) results revealed
that the informal (that is, support from relatives and friends)
and formal (that is, support from health professionals) so-
cial support of MOW program participants and nonpartici-
pants were notably different from one another. As
compared to nonparticipants, MOW program participants
were less likely to have received support from their mothers
(OR 4 0.5, 95% CI 4 0.3, 0.7; p 4 0.001), the baby’s
father (OR 4 0.3, 95% CI 4 0.2, 0.6; p 4 0.001), other
relatives (OR 4 0.5, 95% CI 4 0.3, 0.8; p 4 0.001), and
friends (OR 4 0.4, 95% CI 4 0.3, 0.7; p 4 0.001). The
average number of informal support sources was 1.7 (SD
4 1.0) for MOW program participants and 2.5 (SD 4
1.5) for nonparticipants (p 4 0.001). The intensity of
support provided by either relatives or friends, however,
did not differ significantly between the two groups.
Significant differences were also found in the sources
of formal support between MOW program participants and
nonparticipants. By design, only mothers who participated
in the MOW program received social support from home
visitors. Compared to nonparticipants, however, MOW
program participants were far less likely to have received
support from their doctors (OR 4 0.2, 95% CI 4 0.1,
0.4; p 4 0.001), and nurses (OR 4 0.5, 95% CI 4 0.3,
0.8; p 4 0.001).
Psychological Functioning
Crude (unadjusted) comparisons of the average psycho-
logical functioning scores between MOW program partici-
pants and nonparticipants during pregnancy and 1 year
after delivery are presented in Table 3. Significant differ-
ences were found in the mean self-esteem (p 4 0.004)
and depression (p 4 0.007) scores during pregnancy
between MOW program participants and nonparticipants,
with the former group having slightly lower levels of
284 Public Health Nursing Volume 17 Number 4 July/August 2000

TABLE 1. Sociodemographic Characteristics of MOW Program Participants (n 4 221) and Non-Participants (n 4 198)
MOW Non-MOW Odds Ratio
Variable n (%) n (%) (95% CI)a P-Value
Age (years)
12–19 years 136 (62) 103 (52) 1.5 (1.0, 2.2) 0.049*
$20 years 85 (38) 95 (48) (referent)
Race
African American 142 (64) 109 (55) 1.6 (1.1, 2.5) 0.020*
Other 17 (8) 11 (6) 1.9 (0.8, 4.5) 0.112
White 62 (28) 78 (39) (referent)
Marital status
Unmarried 186 (84) 143 (72) 2.0 (1.3, 3.3) 0.003**
Married 35 (16) 55 (28) (referent)
Education
< High school 162 (73) 104 (53) 2.5 (1.7, 3.7) 0.001**
$ High school 59 (27) 94 (47) (referent)
Annual family incomeb
$<15,000 150 (84) 137 (70) 2.3 (1.4,3.9) 0.001**
$$15,000 28 (16) 60 (30) (referent)
Employment status (part- or full-time)b
Unemployed 47 (44) 38 (33) 1.5 (0.9, 2.7) 0.119
Employed 61 (56) 76 (67) (referent)
a
Crude (unadjusted) odds ratio; CI 4 confidence interval.
b
Results reported on available data, some participant data are missing.
*Denotes significance at 5% level and **denotes significance at <1% level using the Cochran Mantel-Haenszel Chi-Square test.

self-esteem and greater levels of depression. Differences
in the mean perceived stress scores during pregnancy
were borderline significant between the two groups (p 4
0.061), with MOW program participants having slightly
higher levels of perceived stress. In contrast, 1 year after
delivery, the psychological functioning levels of MOW
program participants did not differ significantly from
nonparticipants.
Mean crude (unadjusted) changes in the mothers’ self-
esteem and perceived stress scores from pregnancy to 1
year after delivery were not significantly different between
MOW program participants and nonparticipants, however,
a significant difference was found when changes in depres-
sion were examined (Table 3). On average, depression
scores increased by 2.07 (SD 4 12.81) for MOW program
participants compared to 5.10 (SD 4 11.60) for nonpartici-
pants (p 4 0.012). This finding suggests that although
mothers in both groups were slightly more depressed 1
year after delivery than during pregnancy, the observed
increase in depression was significantly greater for nonpar-
ticipants, as compared to MOW program participants.
Type and Intensity of Home Visits and Psychological
Functioning
As shown in Table 4, crude (unadjusted) results indicated
no significant associations between the type of support
provided by home visitors (emotional, instrumental, infor-
mational) and changes in the MOW program participants’
levels of self-esteem, perceived stress, or depression. The
intensity of home visitor support, however, was strongly
associated with improvements in the program participants’
self-esteem levels (p 4 0.001); that is, participants who
had more frequent support from their home visitors had
greater improvements in their self-esteem than participants
who had less frequent support from their home visitors. In
contrast, no significant associations were observed between
the intensity of home visitor support and changes in the
MOW program participants’ perceived stress and depres-
sion levels.
Multivariate Analyses
Three linear regression models examined self-esteem, per-
ceived stress, and depression (that is, psychological func-
tioning) 1 year after delivery as a function of the intensity
of MOW program participation (no participation in the
MOW program, MOW program participation with less
intensive home visitor support, or MOW program partici-
pation with more intensive home visitor support), taking
into account sources of informal and formal support and
potential confounders (Table 5). The results of the self-
esteem model revealed that, compared to nonparticipants,
MOW program participants with more intensive home visi-
tor support (that is, home visits provided fairly or very
 Navaie-Waliser et al.: Social Support and Psychological Functioning 285

TABLE 2. The Informal and Formal Social Support Structures of MOW Program Participants (n 4 221) and Non-Participants
(n 4 198)
MOW Non-MOW Odds Ratio P-Value
Variable n (%) n (%) (95% CI)a
Source of informal social support
Pregnant woman’s motherb
Yes 132 (60) 149 (76) 0.5 (0.3, 0.7) 0.001*
No 88 (40) 47 (24) (referent)
Baby’s father c
Yes 22 (10) 48 (25) 0.3 (0.2, 0.6) 0.001*
No 198 (90) 144 (75) (referent)
Other relativesb
Yes 81 (37) 104 (53) 0.5 (0.3, 0.8) 0.001*
No 139 (63) 91 (47) (referent)
Friendsc
Yes 42 (19) 70 (36) 0.4 (0.3, 0.7) 0.001*
No 178 (81) 123 (64) (referent)
Intensity of support from relatives
Visits fairly/very often 169 (76) 150 (76) 1.0 (0.7,1.6) 0.864
Visits almost never/sometimes 52 (24) 48 (24) (referent)
Intensity of support from friends
Visits fairly/very often 125 (57) 116 (59) 0.9 (0.6, 1.4) 0.676
Visits almost never/sometimes 96 (43) 82 (41) (referent)
Formal social support from sources other than home visitors
Doctorsc
Yes 41 (19) 98 (51) 0.2 (0.1,0.4) 0.001*
No 179 (81) 96 (49) (referent)
Nursesc
Yes 41 (19) 62 (32) 0.5 (0.3,0.8) 0.001*
No 179 (81) 129 (68) (referent)
a
Crude (unadjusted) odds ratio; CI 4 confidence interval.
b
Data are missing for one participant in the MOW group and two participants in the non-MOW group.
c
Data are missing for one participant in the MOW group and between four to six participants in the non-MOW group.
*Denotes significance at <1% level using the Cochran Mantel-Haenszel Chi-Square test.

often) had significantly higher self-esteem levels 1 year
after delivery, after adjusting for sources of support other
than home visitors, baseline self-esteem levels, age, race,
and marital status (p 4 0.039). MOW program participants
with less intensive home visitor support (that is, home
visits provided almost never or sometimes), however, did
not differ significantly from nonparticipants in their self-
esteem levels 1 year after delivery. Furthermore, no associ-
ations were found between support provided by the preg-
nant woman’s mother, the baby’s father, other relatives,
friends, doctors, and nurses and the mothers’ self-esteem
levels 1 year after delivery.
No significant differences were observed in the per-
ceived stress levels of mothers who participated in the
MOW program as compared with nonparticipants 1 year
after delivery, regardless of the intensity of home visitor
support, after adjusting for sources of support other than
home visitors, baseline perceived stress levels, age, race,
and marital status. Mothers who had support from the
baby’s father, however, were found to have significantly
lower perceived stress levels 1 year after delivery, as com-
pared with mothers who did not have support from the
baby’s father (p 4 0.046).
The depression model revealed that, compared to non-
participants, MOW program participants with more inten-
sive home visitor support (that is, home visits provided
fairly or very often) were significantly less depressed 1
year after delivery, after adjusting for sources of support
other than home visitors, baseline depression levels, age,
race, and marital status (p 4 0.015). In contrast, mothers
who participated in the MOW program and who received
less intensive home visitor support (that is, home visits
provided almost never or sometimes) did not have signifi-
cantly different depression levels 1 year after delivery than
nonparticipants. Furthermore, no associations were found
between support provided by the pregnant woman’s
286 Public Health Nursing Volume 17 Number 4 July/August 2000

TABLE 3. Mean Psychological Functioning Scores of MOW Program Participants (n 4 221) and Non-Participants (n 4 198)
MOW Non-MOW
Variable Mean Score (5 SD) a
Mean Score (5 SD)a P-Value
Psychological functioning during pregnancy (baseline)
Self-esteem 29.47 (4.56) 30.80 (4.79) 0.004**
Perceived stress 28.94 (6.91) 27.62 (7.42) 0.061
Depression 23.75 (12.01) 20.57 (11.82) 0.007**
Psychological functioning 1 year after delivery
Self-esteem 30.98 (4.81) 31.75 (4.76) 0.101
Perceived stress 26.36 (7.30) 25.30 (7.25) 0.136
Depression 25.82 (9.74) 25.67 (10.04) 0.874
Change in psychological functioning scoresb
Self-esteem 1.51 (4.38) 0.95 (4.21) 0.189
Perceived stress 12.58 (7.59) 12.32 (8.53) 0.748
Depression 2.07 (12.81) 5.10 (11.60) 0.012*
a
SD 4 standard deviation.
b
Change for each outcome was computed based on differences in the mothers’ psychological functioning scores 1 year after delivery
as compared to during pregnancy (Time 2 scores–Time 1 scores).
*Denotes significance at 5% level and **denotes significance at <1% level using the Student’s t test.

TABLE 4. Mean Changes in Psychological Functioning Scores of MOW Program Participants (n4221) in Relation to the Type
and Intensity of Support Provided by Home Visitors
Self-Esteem Perceived Stress Depression
Mean Change Mean Change Mean Change
Variable Score (5 SD)ab P-Value Score (5 SD)ab P-Value Score (5 SD)ab P-Value
Type of support provided
Emotional
Yes 1.55 (4.65) 0.766 12.56 (8.00) 0.985 2.94 (12.83) 0.120
No 1.38 (3.72) 12.58 (6.56) 10.01 (12.64)
Instrumental
Yes 1.61 (4.35) 0.315 12.62 (7.28) 0.814 2.06 (12.31) 0.982
No 0.65 (4.72) 12.13 (9.94) 2.14 (16.72)
Informational
Nutrition
Yes 1.66 (4.45) 0.100 12.64 (7.74) 0.674 1.83 (12.89) 0.390
No 0.01 (3.34) 11.90 (6.07) 4.36 (12.10)
Family planning
Yes 1.56 (4.73) 0.540 12.62 (5.49) 0.995 1.93 (12.84) 0.994
No 0.88 (4.01) 12.63 (5.49) 1.91 (10.65)
Infant care
Yes 1.61 (4.48) 0.260 12.67 (7.55) 0.550 1.85 (12.66) 0.428
No 0.45 (3.17) 11.60 (8.04) 4.24 (14.44)
Intensity of support provided
Visits fairly/very often 2.16 (4.18) 0.001** 13.06 (7.65) 0.172 1.36 (12.97) 0.164
Visits almost never/sometimes 0.08 (4.56) 11.55 (7.21) 4.07 (11.26)
a
SD 4 standard deviation.
b
Change for each outcome was computed based on differences in the mothers’ psychological functioning scores 1 year after delivery
as compared to during pregnancy (Time 2 scores–Time 1 scores).
**Denotes significance at <1% level using the Student’s t test.
 Navaie-Waliser et al.: Social Support and Psychological Functioning 287

TABLE 5. Linear Regression Results of the Impact of the MOW Program on Mothers’ Psychological Functioning 1 Year After
Delivery
Variable Regression Coefficient (95% CI)b P-Value
Self-esteem model (n 4 407) ac

MOW program participation with less intensive home visitor 10.93 (12.09, 0.23) 0.114
support
MOW program participation with more intensive home visitor 0.95 (0.05, 1.85) 0.039*
support
Informal social support
Pregnant woman’s mother 0.47 (10.40, 1.34) 0.289
Baby’s father 0.75 (10.33, 1.83) 0.172
Other relatives 0.57 (10.23, 1.36) 0.164
Friends 10.44 (11.40, 0.52) 0.366
Formal social support
Doctors 0.42 (10.55, 1.38) 0.400
Nurses 10.30 (11.31, 0.73) 0.575
Control variables
Baseline self-esteem level 0.61 (0.53, 0.69) 0.000**
Age 10.03 (10.10, 0.04) 0.416
Race 10.05 (10.91, 0.80) 0.903
Marital status 10.56 (11.60, 0.48) 0.288
Perceived stress model (n 4 407)ac
MOW program participation with less intensive home visitor 0.53 (11.47, 2.52) 0.605
support
MOW program participation with more intensive home visitor 10.77 (12.32, 0.78) 0.330
support
Informal social support
Pregnant woman’s mother 0.32 (11.19, 1.83) 0.677
Baby’s father 11.91 (13.80, 10.03) 0.046*
Other relatives 1.00 (10.40, 2.38) 0.163
Friends 10.49 (12.15, 1.17) 0.564
Formal social support
Doctors 11.28 (12.96, 0.40) 0.135
Nurses 0.08 (11.69, 1.84) 0.932
Control variables
Baseline perceived stress level 0.42 (0.32, 0.51) 0.000**
Age 10.01 (10.14, 0.11) 0.877
Race 1.11 (10.37, 2.59) 0.142
Marital status 10.98 (12.79, 0.83) 0.287
(continued)

mother, the baby’s father, other relatives, friends, doctors,
and nurses and the mothers’ depression levels 1 year after
delivery.
Additional analyses revealed that neither the type of
support provided by home visitors nor the intensity of
support from relatives and friends was significantly associ-
ated with the mothers’ self-esteem, perceived stress, or
depression levels 1 year after delivery.
DISCUSSION
The results of this investigation suggest that merely partici-
pating in a maternal home visitation program does not
increase the likelihood that women’s psychological func-
tioning will improve over time. Instead, the intensity of
home visitor support seems to be more relevant. Past stud-
ies have not examined the effect of program intensity when
evaluating the impact of home visitation programs on psy-
chological health. Thus, this study’s results can be only
partly compared with findings from other reports. Although
limited in number, previous investigations have reported
no associations between participation in home visitation
programs and changes in women’s self-esteem (Mar-
cenko & Spence, 1994) or depression levels (Oakley et
al., 1990; Marcenko & Spence, 1994; Kitzman et al., 1997).
These negative findings partially concur with this investi-
288 Public Health Nursing Volume 17 Number 4 July/August 2000

TABLE 5. Continued
Variable Regression Coefficient (95% CI)b P-Value
Depression model (n 4 407) ac

MOW program participation with less intensive home visitor 0.88 (11.96, 3.72) 0.542
support
MOW program participation with more intensive home visitor 12.57 (14.64, 10.50) 0.015*
support
Informal social support
Pregnant woman’s mother 10.11 (12.15, 1.93) 0.913
Baby’s father 10.48 (12.05, 3.01) 0.707
Other relatives 11.50 (13.36, 0.37) 0.116
Friends 10.17 (12.41, 2.07) 0.883
Formal social support
Doctors 10.67 (12.93, 1.59) 0.883
Nurses 0.52 (11.87, 2.92) 0.562
Control variables
Baseline depression level 0.33 (0.25, 0.40) 0.000**
Age 0.07 (10.10, 0.24) 0.431
Race 0.28 (11.71, 2.27) 0.784
Marital status 2.91 (0.48, 5.33) 0.019*
a
Models regressed either self-esteem, perceived stress, or depression scores 1 year after delivery {continuous} as a function of the
intensity of MOW program participation {two indicator variables were used, one for MOW program participants with less intensive
home visitor support (that is, home visits provided almost never or sometimes), and another for MOW program participants with
more intensive home visitor support (that is, home visits provided fairly or very often) as compared to mothers who did not
participate in the MOW program as the referent group}, informal social support {0 = no support provided by each of the sources
indicated, 1 4 support provided by each of the sources indicated}, formal social support {0 = no support provided by each of the
sources indicated, 1 4 support provided by each of the sources indicated}, adjusting for baseline psychological functioning level
{continuous}, age {continuous}, race {0 = non-African American, 1 4 African American}, and marital status {0 = married, 1 4
unmarried}.
b
CI 4 confidence interval.
c
Data are missing for 12 mothers.
*Denotes significance at 5% level and **denotes significance at <1% level.

gation’s results since no significant improvements in wom-
en’s self-esteem or depression levels were found for women
with less intensive home visitor support. Modest but signif-
icant improvements in both self-esteem and depression
levels, however, were observed for women with more in-
tensive home visitor support. These findings point to two
important issues. First, observations of only modest im-
provements in self-esteem and depression are not unex-
pected given that psychological health is not likely to
change much over relatively short time periods, especially
among socially disadvantaged populations (Rosenberg,
1981; Pierce et al., 1996). Hence, given that this investiga-
tion focused on high-risk Medicaid-eligible women with
fairly poor psychological health, it may not be realistic to
expect considerable changes in their psychological func-
tioning within 1 year after delivery. Second, finding that
the intensity of home visitor support may be linked to
aspects of women’s psychological health suggests the pres-
ence of a potential dose-response relationship. Thus, since
multiple factors (for example, scheduling conflicts, partici-
pant compliance, limited number of home visitors) can
affect the ability to provide intensive home visits, a stronger
focus on minimizing factors that inhibit this ability may
be warranted in order to increase the potential impact of
maternal home visitation programs.
Past studies have not reported the effects of maternal
home visitation programs on women’s perceived stress
levels. This study found no significant changes in the per-
ceived stress levels of women 1 year after delivery, irre-
spective of the intensity with which they were provided
home visitor support. Although social support has been
shown to reduce perceived stress (Cohen & Willis, 1985;
Krause, 1986, 1987; Hoffman & Hatch, 1993) and to miti-
gate poor psychological functioning among low-risk moth-
ers (Seguin et al., 1995), this may not be applicable to high-
risk mothers who face a multitude of stressors. Another
consideration is the negative but significant correlation
observed between the mothers’ self-esteem and perceived
 Navaie-Waliser et al.: Social Support and Psychological Functioning 289
stress levels (not shown), a relationship that has been shown
to synergistically counteract the potential benefits of social
support (Cohen et al., 1997).
An examination of the effects of various sources of
support other than home visitors on women’s psychological
functioning revealed that support from the baby’s father
was significantly associated with lower levels of perceived
stress. This finding is consistent with past studies which
have shown that partner support is an important contributor
to positive maternal psychological health (Beach, Fincham,
Katz, & Bradbury, 1996; Dunkel-Shetter, Sagrestano, Feld-
man, & Killingsworth, 1996; Pierce et al., 1996).
One of the objectives of this investigation was to deter-
mine whether improvements in the mothers’ psychological
functioning were associated with the type of social support
provided by home visitors (emotional, instrumental, infor-
mational), a question that has not been addressed pre-
viously in the literature on maternal home visitation
programs. Although the results revealed that the type of
social support provided by home visitors was not associated
with changes in the mothers’ psychological functioning,
this finding must be viewed cautiously since there can be
considerable overlap between these types of support. Thus,
the three categories of support type may not have been
mutually exclusive, a potential explanation for the observed
lack of effect. Nevertheless, this finding, along with the
observation that the intensity of home visitor support is an
important component of home visitation programs, suggest
that these programs may have a greater impact on women’s
psychological health if they direct more of their attention
on providing frequent home visits, and focus less on the
type of visit provided.
Although the results of this investigation provide further
insight about the impact of maternal home visitation pro-
grams on mothers’ psychological functioning, the findings
must be viewed in light of this study’s limitations. First,
all of the data were obtained from personal interviews and
are therefore subject to all of the biases associated with
self-reported information (Rothman, 1986). Second, this
evaluation was quasi-experimental in design and did not
include a randomized sample. Third, selection bias may
have been present due to the somewhat different referral
patterns used by the health departments and community
health centers that housed the MOW program since they
had considerable autonomy in implementing the interven-
tion. Thus, since each of the nine counties from which the
MOW program participants were selected had latitude in
choosing its target population and designating the home
visitors’ duties, in essence, we may not be looking at a
single, homogeneous MOW program.
The fairly large attrition rates observed in this study may
have led to selection bias (Rothman, 1986). A comparison
of the sociodemographic characteristics between dropouts
from the MOW program participant and nonparticipant
groups, however, revealed no significant differences. Al-
though the potential reasons contributing to the observed
attrition are unclear, they are likely to be multifactorial
and include substance use and a lack of perceived needs
(Navaie-Waliser et al., 2000).
Another potential limitation was the difficulty in achiev-
ing a high degree of comparability between MOW program
participants and nonparticipants. As shown earlier, a com-
parison of the sociodemographic and psychological charac-
teristics of the study participants suggested that the women
who were referred from the comparison counties were not
as high risk as the women who were referred from the
MOW counties (those actually receiving home visits), even
though the maternity care coordinators from comparison
counties were asked to only refer women to this evaluation
study that they would have linked to the MOW program
if the program had been available in their counties. This
could have resulted in a sample selection biased against
the measurement of positive program effects.
Lastly, it should be kept in mind that the crude odds ratios
generated in this study pertained to three psychological
functioning outcomes, none of which was a rare event;
therefore, these odds ratios will tend to be less accurate
than crude relative risk estimates.
Despite the limitations, this study adds to the present
knowledge about the impact of maternal home visitation
programs on women’s psychological health by suggesting
that more intensive levels of home visitor support are likely
to improve certain aspects of psychological functioning
among women at high risk for poor psychological health.
These findings, however, were based on a relatively short
period during which home visitation services were pro-
vided. It may be that the provision of home visitation
services over longer periods are necessary to observe a
larger degree of positive programmatic effects on women’s
psychological health.
Considering the potentially devastating consequences of
poor maternal psychological health such as suicide, poor
maternal-child bonding, child abandonment, and child
abuse, future studies should continue to investigate the
preventive role, if any, of social support intervention pro-
grams. Attention also should be given to differentiating the
various contributing factors to poor maternal psychological
health. It may be that different factors play a role in self-
esteem, perceived stress, and depression levels prepartum
than postpartum, as has been suggested recently (Pierce et
al., 1996). Knowledge about what and when specific factors
may be present could help to determine the potential level
of impact that can realistically be expected from social
support-based maternal home visitation programs.
290 Public Health Nursing Volume 17 Number 4 July/August 2000
ACKNOWLEDGMENTS
This research was supported, in part, by the Association
for the Schools of Public Health and the Centers for Disease
Control and Prevention (Grant #32–1065), the Kate B.
Reynolds Charitable Trust, and the North Carolina Depart-
ment of Environment, Health, and Natural Resources. The
authors thank Drs. Andrea K. Biddle, Pierre Buekens, Mil-
ton Kotelchuck, and David A. Savitz, along with this jour-
nal’s anonymous reviewers, for their constructive
suggestions on earlier drafts of this paper.
REFERENCES
Barnet, B., Joffe, A., Duggan, A. K., & Wilson, M. D. (1996).
Depressive symptoms, stress, and social support in pregnant
and postpartum women. Archives of Pediatrics and Adolescent
Medicine, 150, 64–69.
Beach, S. R., Fincham, F. D., Katz, J., & Bradbury, T. N. (1996).
Social support in marriage: A cognitive perspective. In G. R.
Pierce, B. R. Sarason, & I. G. Sarason (Eds.), Handbook of
social support and the family (pp. 43–65). New York: Plenum
Press.
Brown, D. R., Gray, L. E., Greene, A. D., & Milburn, N. G.
(1992). Patterns of social affiliation as predictors of depressive
symptoms among urban blacks. Journal of Health and Social
Behavior, 33, 242–253.
Cohen, L. H., Hettler, T. R., & Park, C. L. (1997). Social support,
personality, and life stress adjustment. In. G. R. Pierce, B.
Laskey, I. G. Sarason, & B. R. Sarason (Eds.), Sourcebook
of social support and personality (pp. 215–228). New York:
Plenum Press.
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global
measure of perceived stress. Journal of Health and Social
Behavior, 24, 385–396.
Cohen, S., & Willis, T. A. (1985). Stress, social support and the
buffering hypothesis. Psychological Bulletin, 98, 310–357.
Collins, N. L., Dunkel-Schetter, C., Lobel, M., & Scrimshaw,
S. C. M. (1993). Social support in pregnancy: Psychosocial
correlates of birth outcomes and postpartum depression. Jour-
nal of Personality and Social Psychology, 65, 1243–1258.
Copper, R. L., Goldenberg, R. L., Das A., Elder, N., Swain, M.,
Norman, G., Ramsey, R., Cotrones, P., Collins, B. A., Johnson,
F., Jones, P., & Meier, A. M. (1996). The preterm prediction
study: Maternal stress is associated with spontaneous preterm
birth at less than thirty-five weeks’ gestation. American Jour-
nal of Obstetrics and Gynecology, 175, 1286–1292.
Cross, A., & McGloin, T. (1992). The Helping Families Program:
A final report to the Kate B. Reynolds Health Care Trust and
the Jessie Ball DuPont Educational Fund. Chapel Hill, NC:
Center for Health Promotion and Disease Prevention, Univer-
sity of North Carolina.
Cutrona, C. E., & Russell, D. W. (1990). Type of social support
and specific stress: Toward a theory of optimal matching. In
B. R. Sarason, I. G. Sarason, & G. R. Pierce (Eds.), Social
support: An interactional view (pp. 319–366). New York:
John Wiley & Sons.
Dunkel-Shetter, C., Sagrestano, L. M., Feldman, P., & Kill-
ingsworth, C. (1996). Social support and pregnancy: A com-
prehensive review focusing on ethnicity and culture. In G. R.
Pierce, B. R. Sarason, & I. G. Sarason (Eds.), Handbook of
social support and the family (pp. 375–412). New York: Ple-
num Press.
Gjerdingen, D. K., & Chaloner, K. M. (1994). The relationship
of women’s postpartum mental health to employment, child-
birth, and social support. Journal of Family Practice, 38,
465–472.
Heins, H. C., Nancy, N. W., & Ferguson, J. E. (1987). Social
support in improving perinatal outcome: The Resource Moth-
ers Program. Obstetrics and Gynecology, 70, 263–266.
Hoffman, S., & Hatch, M. C. (1993). Stress, social support and
pregnancy outcome: A reassessment based on recent research.
Paediatric and Perinatal Epidemiology, 10, 380–405.
Jung, J. (1997). Balance and source of social support in relation
to well-being. Journal of General Psychology, 124, 77–90.
Kitzman, H., Olds, D. L., Henderson, C. R., Jr., Hanks, C., Cole,
R., Tatelbaum, R., McConnochie, K. M., Sidora, K., Luckey,
D. W., Shaver, D., Englehardt, K., James, D., & Barnard, K.
(1997). Effect of prenatal and infancy home visitation by
nurses on pregnancy outcomes, childhood injuries, and re-
peated childbearing. Journal of the American Medical Associ-
ation, 278, 644–652.
Krause, N. (1986). Social support, stress, and well-being. Journal
of Gerontology, 41, 512–519.
Krause, N. (1987). Understanding the stress process: Linking
social support with locus of control beliefs. Journal of Geron-
tology, 42(6), 589–593.
Langford, C. P., Bowsher, J., Maloney, J. P., & Lillis, P. J. (1997).
Social support: A conceptual basis. Journal of Advanced Nurs-
ing, 25, 95–100.
Logsdon, M. C. (1994). Social support and postpartum depres-
sion. Research in Nursing and Health, 17, 449–457.
Marcenko, M. O., & Spence, M. (1994). Home visitation
services for at-risk pregnant and parenting women: A ran-
domized trial. American Journal of Orthopsychiatry, 64,
468–478.
McDowell, I., & Newell, C. (1996). Measuring health: A guide
to rating scales and questionnaires. New York: Oxford Uni-
versity Press.
Navaie-Waliser, M., Martin, S. L., Campbell, M. K., Tessaro, I.,
Kotelchuck, M., & Cross, A. W. (2000). Factors predictive
of program completion by high-risk pregnant women: The
experience of the North Carolina Baby Love Maternal Out-
reach Worker Program. American Journal of Public Health,
90(1), 121–123.
Norbeck, J. S. (1981). Social support: A model for clinical re-
search. Advances in Nursing Sciences, 7, 43–59.
Norbeck, J. S., DeJoseph, J. F., & Smith, R. T. (1996). A. random-
ized trial of an empirically-derived social support intervention
to prevent low birth weight among African-American women.
Social Science and Medicine, 43, 947–954.
Oakley, A., Rajan, L., & Grant, A. (1990). Social support and
pregnancy outcome. British Journal of Obstetrics and Gyne-
cology, 97(2), 155–162.
 Navaie-Waliser et al.: Social Support and Psychological Functioning 291
Olds, D. L., Henderson, C. R., Jr., Tatelbaum, R., & Chamberlin,
R. (1986). Improving the delivery of prenatal care and out-
comes of pregnancy: A randomized trial of nurse home visita-
tion. Pediatrics, 77, 16–28.
Pierce, G. R., Sarason, B. R., Sarason, I. G., Joseph, H. J., &
Henderson, C. A. (1996). Conceptualizing and assessing social
support in the context of the family. In. G. R. Pierce, B. R.
Sarason, & I. G. Sarason (Eds.), Handbook of social support
and the family (pp. 3–23). New York: Plenum Press.
Radloff, L. S. (1977). The CES-D scale: A self-report depression
scale for research in general populations. Applied Psychology
Measurements, 1, 385–401.
Rosenberg, M. (1979). Conceiving the self (pp. 291–297). New
York: Basic Books.
Rosenberg, M. (1981). The self concept: Social products and
social forces. In M. Rosenberg & R. H. Turner (Eds.), Social
psychology: Sociological perspectives (pp. 593–624). New
York: Basic Books.
Rothman, K. J. (1986). Modern epidemiology. Boston: Little
Brown.
SAS Institute. (1996). Statistical analysis systemt (Version 6.12).
Cary, NC: The SAS Institute.
Seguin, L., Potvin, L., St. Dennis, M., & Loiselle, J. (1995).
Chronic stressors, social support, and depression during preg-
nancy. Obstetrics and Gynecology, 85, 583–589.
State Center for Health and Environmental Studies, Department
of Environment, Health, and Natural Resources. (1995). North
Carolina vital statistics. Raleigh, NC: Department of Environ-
ment, Health, and Natural Resources.
Tessaro, I., Campbell, M. K., O’Meara, C., Herrick, H., Buescher,
P., Meyer, R., McGloin, T., Roth, M., & Cross, A. W. (1997).
State health department and university evaluation of North
Carolina’s Maternal Outreach Worker Program. American
Journal of Preventive Medicine, 13, 38–44.
Wadhwa, P. D., Sandman, C. A., Porto, M., Dunkel-Schetter,
C., & Garite, T. J. (1993). The association between prenatal
stress, infant birth weight and gestational age at birth: A
prospective investigation. American Journal of Obstetrics and
Gynecology, 169, 858–865.
Warren, B. J. (1997). Depression, stressful life events, social
support, and self-esteem in middle class African-American
women. Archives of Psychiatric Nursing, 11, 107–117.
Zuckerman, B., Bauchner, H., Parker, S., & Cabral, H. (1990).
Maternal depressive symptoms during pregnancy and new-
born irritability. Journal of Development and Behavioral Pedi-
atrics, 11, 190–194.