Matern Child Health J (2011) 15:1011–1019
DOI 10.1007/s10995-010-0662-z
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
Published online: 13 August 2010
 Springer Science+Business Media, LLC 2010
Abstract 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
M. L. Holland acknowledges support from an NRSA Institutional
Research Training Grant (T32 HS000044-16) and a Health Services
Research Dissertation Award (R36 HS017737), both from the Agency
for Healthcare Research and Quality. The authors would like to thank
Constance Baldwin, PhD for her assistance in critically revising this
manuscript.
M. L. Holland
P. G. Szilagyi
Department of Pediatrics, University of Rochester School
of Medicine and Dentistry, Rochester, NY, USA
M. L. Holland (&)
H. Kitzman
School of Nursing, University of Rochester School of Medicine
and Dentistry, 601 Elmwood Ave, Box SON, Rochester,
NY 14642, USA
e-mail: margaret_holland@urmc.rochester.edu
B.-K. Yoo
H. Temkin-Greener
Department of Community and Preventive Medicine,
University of Rochester School of Medicine and Dentistry,
Rochester, NY, USA
L. Chaudron
Department of Psychiatry, University of Rochester
School of Medicine and Dentistry, Rochester, NY, USA
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 sin-
gle model, the depressive symptoms coefficient decreased
significantly (OR decreased by 0.13, P = 0.069), support-
ing the hypothesis that self-efficacy serves as a mediator. A
non-linear, inverse-U shaped relationship between mater-
nal 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.
Keywords Maternal depression
Self-efficacy

Healthcare utilization
Child health
Low income
Numerous studies have found higher rates of child hospi-
talizations [1–4] or trends toward more hospitalizations
[5, 6] associated with higher levels of maternal depression.
While some child hospitalizations are necessary, others are
associated with missed or delayed preventive care [7, 8],
which can lead to poorer outcomes and higher health-
care costs. Avoidable hospitalizations include vaccine-
preventable illness, acute illnesses potentially manageable
in ambulatory care such as dehydration, and chronic illness
exacerbations such as asthma flare-ups [7]. We estimate that
$438 million is spent annually on excess hospitalizations
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1012
associated with maternal depression for low-income young
children.1
The reason for the apparent association between
maternal depression and child hospitalizations is unknown.
The association may arise from factors that impact the
likelihood of both maternal depression and child hospital-
ization, such as low socio-economic status (SES) [1] or
serious and/or chronic child health conditions [12].
Maternal depression is associated with underuse of pre-
ventive care [6], perhaps because depressed mothers have
lower energy to schedule and attend visits, which in turn
may contribute to a child’s later need for hospitalization. In
addition, depression may contribute to child injuries
through inadequate supervision and difficulty maintaining
a safe environment [13]. The direction of the association is
not clear, however. Although maternal depression may
precede increased child hospitalization, caring for a child
with greater health risks may also contribute to maternal
depression [14]. Associations between maternal depression
and child hospitalizations have been reported from studies
measuring depressive symptoms either before or after
hospital utilization, so a bidirectional association may exist
[4, 15]. Understanding the mechanisms underlying this
relationship might shed light on potential interventions.
One possible mechanism involves maternal self-efficacy.
Several authors have hypothesized that depressed mothers
have more difficulty coping with both an ill child [6, 16] and
the medical system [17], possibly because of low self-effi-
cacy [18]. Self-efficacy is defined as the belief that one is
able to be effective at a certain task, such as parenting.
Depression and self-efficacy are inversely related [19, 20];
specifically, maternal depression is associated with low
parenting self-efficacy [21]. Negative perspectives common
in depression could make a woman feel less capable of
providing care for her child and more likely to recall pre-
vious negative situations that support this feeling [18, 22]. A
mother with low parenting self-efficacy may delay seeking
care due to lack of confidence in making healthcare deci-
sions, thus allowing the child’s condition to worsen. In
addition, the child’s medical provider may be more likely to
recommend hospitalization if the mother’s lack of parenting
self-efficacy broadcasts signs that the child may not receive
appropriate care at home [15]. Any of these scenarios could
increase the likelihood of child hospitalization, but no
hypothetical explanations have been empirically tested.
SES is an important factor to consider in any study of
maternal capabilities and child outcomes, because its
1
This estimate is based on the following values: average hospital-
ization cost per child ($466 if public or no insurance [9]), prevalence
of maternal depression in low-income populations (lowest estimate:
27% [10]), odds ratio (OR) of hospitalization for children of
depressed mothers (1.8 [2]), and number of children (5.3 million
under 6 years old living in poverty [11]).
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Matern Child Health J (2011) 15:1011–1019
effects are so pervasive. First, low SES is a risk factor for
depression [23–25]. Prevalence rates for low-income
mothers range from 27 to 53% [10, 26, 27]. Second, low-
income families also have higher hospitalization rates
[1, 3] and lower rates of well-child care [28, 29] than the
general population. Low-income families may have
restricted access to primary care due to poor insurance
coverage, scheduling challenges at low-paying jobs, and
limited transportation. Reduced primary care use may
increase hospitalizations due to delayed or foregone care.
Lack of education and resources may also increase hospi-
talization, if these contribute to unsafe environments that
result in more injuries, increased exposure to asthma trig-
gers, or exposure to violence. Finally, health-related self-
efficacy tends to be lower among low-income parents [30].
In an inner-city population, self-perceived parenting com-
petence was a better predictor of risk for depression than
known demographic risks [31]. Because each of these
factors (maternal depression, child hospitalizations, and
self-efficacy) is worse in low-income populations, the
relationships among these factors are important to study.
In addition to maternal depression, self-efficacy, and
low SES, it is important to consider other factors that have
been shown to be associated with child hospitalizations.
These include: being an unmarried parent [15, 32],
maternal unemployment [15], mother’s educational level of
high school or less [15], low birthweight [33, 34], chronic
health conditions [15, 35], maternal age [32], child’s sex
[32, 34], minority race/ethnicity [34], and presence of other
young children in the household [33]. In addition, the
presence of a grandmother in the household may impact
healthcare use; in many 3-generation households, the
grandmother plays a significant role in childcare [36]. The
factors in this list that are associated either with low-
income populations or poor child health are also risk fac-
tors for maternal depression and low self-efficacy. Thus,
we included them as covariates.
In this study, we examined parenting self-efficacy as a
potential mechanism contributing to the relationship
between maternal depression and child hospitalization in a
low-income population. Specifically, we hypothesized that
low parenting self-efficacy increases child hospitalizations
and is a mediator between maternal depression and child
hospitalizations.
Methods
Study Sample
Study data were obtained from the Nurse-Family Partner-
ship (NFP) trial in Memphis, TN [37]. Only the NFP
control group that was followed past childbirth (n = 515)
Matern Child Health J (2011) 15:1011–1019
was used for the current study, because the intervention
was expected to influence key variables [37, 38]. Medical
records, interviews, and observations from mother–child
dyads were collected. Primiparous women were recruited
in 1990-91 at the regional obstetrical clinic for Medicaid
recipients and had to meet 2 of 3 high-risk criteria: being
unmarried, being unemployed, or having less than 12 years
of education. Of those eligible, 88% enrolled in the study
and were randomized into 4 groups. Nurses visited 1 group
from pregnancy until children were 24 months old to help
mothers and other caregivers ‘‘improve the physical and
emotional care of their children’’ [37]. All intervention and
control groups were interviewed at intake (during preg-
nancy); the 2 groups followed past childbirth were also
interviewed at 6, 12, and 24 months postpartum. To min-
imize potential biases, some subjects were excluded from
the current study: twins (17); children who died before
24 months (7), those with very low birth weights (12) or
malformations (3); mothers not living with the study child
(15); and children whose medical records were incomplete
(37). The final dataset (n = 432) represented a fairly
homogeneous group with similar access to healthcare.
Most children were covered by Medicaid (96% ever cov-
ered; 70% for at least 18 of 24 months). Demographic
characteristics are shown in Table 1.
Dependent Variable
We analyzed the number of child hospitalizations from
birth through 24 months. Although we planned to analyze
avoidable hospitalizations separately from unavoidable
hospitalizations, the power was insufficient in this sample.
Using diagnoses from each visit and the definition of
avoidable (or ambulatory-care sensitive) conditions from
Logan et al. [17], 56% of child hospitalizations were
avoidable. In addition, injuries and ingestions were not
considered separately, due to the very small number of
these events (15) [37].
Independent Variables of Interest
We used the Mental Health Inventory-5 (MHI-5) to mea-
sure depressive symptoms. This psychometrically validated
measure consists of 5 items with 5 response categories each
[40–42]. It was rescaled to 0–100; higher score is worse.
When compared to the DSM-IV criteria, the MHI-5 was
found to have 83% sensitivity and 78% specificity when a
threshold of 60 for elevated depressive symptoms was used
[42]. Mothers’ depressive symptoms were measured at
both 12 and 24 months postpartum. A woman was con-
sidered to have consistently elevated depressive symptoms
if the measures were above the DSM-IV based threshold of
60 at both time points. We used consistently elevated
1013
depressive symptoms in our analyses because of evidence
of a stronger relationship with healthcare utilization using
repeated measures of depression, compared to a single
measure [1].
The parenting self-efficacy (SE) scale was created spe-
cifically for the NFP trials, based on Bandura’s work [19].
Mothers were asked a series of 10 questions focusing
on parenting-specific tasks (Cronbach’s alpha = 0.68;
Table 2). Possible scores ranged from 1 (low SE) to 5 (high
SE). The values from the interview at the mid-point of the
study period (i.e., 12 months) were used. Although par-
enting self-efficacy was also measured at 24 months, we
used only the 12 month measure, because it is closer in
time to the events in the first year, precedes the events in
the second year, and self-efficacy tends to be relatively
stable over time [19].
Other Independent Variables: Risk Adjustment
In addition to demographics and risk factors discussed in
the introduction, several other risk factors for hospitaliza-
tion were included as covariates (Table 1). Because many
mothers were younger than 18, maternal education was
coded dichotomously as ‘‘on-track for age’’ or not, based
on the number of years of schooling completed compared
to years expected for her age. The percentage of time the
child was cared for by the father, mother’s boyfriend or
husband was included as a proxy for his influence on
healthcare decisions. We included a measure of household
density (residents per room), because crowded conditions
have been shown to affect parenting [43]. The presence of
a sibling is also likely to influence parenting decisions and
has been used in other studies of healthcare utilization [44].
The presence of any chronic condition (list from Perrin,
et al. [45]) or the use of a bronchodilator were included.
Statistical Analysis
Mediation
For an analysis to support mediation, two requirements
must be met. First, the mediator (self-efficacy) must predict
the outcome (hospitalizations) while controlling for the
independent variable (depressive symptoms). Second, the
mediator must explain a portion of the independent vari-
able’s influence on the outcome (i.e., the coefficient on
depressive symptoms must decrease when SE is added to
the model).
We tested for mediation using 2 ordered logistic
regression models. Model 1 predicted child hospitalizations
using maternal depressive symptoms and the covariates;
Model 2 included SE in addition. To test for mediation, the
depressive symptoms coefficient in Model 2 was compared
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Table 1 Description of sample and variables (n = 432)

Variable Description Mean (SD) or percent

Demographics and risk-adjustment variables

Maternal age At enrollment 18.1 (3.2) range: (12–32)
Race Black 92%
Marital status Mother married at any time in 24 month period after 10.6%
child’s birth
Very low income At or below $3000 annual household income at 47.1%
12 months after child’s birth
Mother’s education Mother ‘‘on-track’’ for completing high school at 59.9%
12 months after child’s birth
Mother’s employment Mother employed at any time in 24 month period 61.9%
after child’s birth
Household density People/rooma at 12 months after child’s birth 0.94 (0.51) range: (0.2–5.0)
Second child Mother has second child before first child is 34.1%
24 months old
Lives with grandmother Mother lives with her mother at 12 months after 51.8%
child’s birth
Child’s sex Male 48.8%
Child chronic condition Any diagnosis for chronic health condition from 25.9%
birth to 24 months or use of bronchodialator, both
from medical records
Child’s birthweight Grams 3127 (497) range: (1585–4540)
Child care by husband/boyfriend/father Husband/boyfriend/father of child cares for child at 26.9%
12 months after child’s birth
Dependent variable
Number of hospitalizations from birth to None 67.6%
24 months 1 21.8%
2 7.4%
3 or more 3.2%
Key independent variables
Maternal depressive symptoms
Consistently high depressive symptoms C40 on MHI-5 at both 12 and 24 months after 13.4%
child’s birth
High depressive symptoms at 12 months C40 on MHI-5; 12 months after child’s birth 28.8%
High depressive symptoms at 24 months C40 on MHI-5; 24 months after child’s birth 36.9%
Parenting self-efficacy Score ranging from 1 to 5; 12 months after child’s 4.24 (0.44) range: (2.6–5.0)
birth
a
Household density of 1 or more is considered ‘‘crowded’’ and 1.5 or more is ‘‘severely crowded’’ [39]

to that in Model 1. All tests in the study used a confidence
level of 90% for determining statistical significance. This
level was chosen to minimize the risk of rejecting a
potential mediator given the relatively small sample size
for mediation analysis. In testing the individual relation-
ships, two-tailed tests were used. To measure change in the
depressive symptoms coefficient, a one-tailed test was used
because only positive values are consistent with mediation.
Multiple imputation by chained equations was used to
handle missing values, using the ‘‘ice’’ and ‘‘micombine’’
commands in Stata, version 10 [46].
Non-Linear Relationships
In analysis of the relation between maternal depression and
child hospitalizations, one could find a simple linear
relationship (i.e., greater levels of maternal depressive
symptoms are related to more child hospitalizations).
Alternatively, there may be a non-linear relationship that
results in an inverse-U shaped curve (i.e., child hospital-
izations peak with elevated maternal depressive symptoms,
but become less frequent for children of mothers with
extremely elevated levels of depression). To test for this

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Table 2 Self-efficacy scale

Question Response scale

In a typical day, how likely are you to read to [CHILD’S NAME]? A

How confident are you that you will read to [CHILD’S NAME] every day during the next week? B
In a typical day, how likely are you to talk to your child every time you feed him/her, change his/ A
her diapers, and give him/her and bath? Would you say…
Please tell me how confident are you that you talk enough with your child every time you feed B
him/her, change his/her diapers, and give him/her and bath? Would you say…
In a typical day, how likely are you to know what your child needs? Would you say… A
How confident are you in your ability to understand your child’s feelings? Would you say… B
How likely are you to gather toys for your child to play with over the next 6 months? A
How confident are you in your ability to find the right toys for your child? B
How likely are you to take child to the doctor’s office or clinic for regular checkups if (he/she) is A
not sick? Would you say…
How confident are you in your ability to get your child to all of the appointments at the clinic or B
doctor’s office if (he/she) is not sick? Would you say…
Scales A: (1) Very unlikely, (2) Unlikely, (3) Somewhat, (4) Likely, (5) Very Likely. B: (1) Not very confident, (2) A little confident, (3)
Somewhat, (4) Confident, (5) Very confident

possible non-linear relationship, we separated depressive
symptoms measured at 12 months into 4 levels. One cut-
off point was based on the literature threshold for elevated
depressive symptoms (60 on MHI-5) and 2 were based on
maximum likelihood in this sample (30 and 35). Model 1
was used to predict hospitalizations. The hypothesized non-
linear relationship between SE and child hospitalizations
was tested in the same fashion, using Model 2. Because
there is no established threshold for SE, the mean value for
this sample was used as one cut-off. Because these mea-
sures are not ratio scales, modeling the non-linear rela-
tionship with a squared term was not appropriate.
Results
This sample consisted primarily of young mothers with
very low income (Table 1), many of whom live in crowded
households that include their own mother. Over one-third
of the mothers gave birth to a second child before their first
child’s second birthday. The child’s father or the mother’s
partner provided childcare for less than one-third of the
children. About one quarter of the children had a chronic
condition or some indication of asthma (diagnosis or use of
a bronchodilator).
At 12 months, 124 (28.8%) of the mothers had elevated
depressive symptoms. Of these women, 58 (46.5%) had
elevated depressive symptoms again at 24 months. Most
children had no hospitalizations (70%) and the majority of
those who did had only 1 (22%). Only 12 children (2.8%)
had 3 or more hospitalizations. Although the self-efficacy
scores were relatively high (mean 4.24 on scale from 1 to
5), there was a reasonable distribution that resembled a
normal distribution; observations were spread across 22
scores, each of 9 scores represented 5% or more of the
observations, and no single score represented more than
10%. The highest score represented 5.3% of the observa-
tions, which is higher than expected for a normal distri-
bution and suggests a slight ceiling effect.
In unadjusted analyses, child hospitalizations were sig-
nificantly associated with consistently high depressive
symptoms, less crowded households, male children, and
child chronic conditions (Table 3). Greater self-efficacy
was associated with children with higher birthweight and
mothers who did not have consistently high depressive
symptoms, were on-track for finishing high school, and
were employed. Consistently high depressive symptoms
were more common in mothers who were younger or not
on-track for finishing high school.
SE was significantly negatively associated with consis-
tently elevated depressive symptoms when all risk-adjust-
ment variables were included in a linear regression model
(b = -0.152, 90% CI: -0.273, -0.031, P = 0.014).
The results of the multivariate models predicting child
hospitalizations are shown in Table 4. Consistently ele-
vated depressive symptoms were significantly associated
with increased child hospitalizations in Model 1, which did
not include SE, but this association did not remain when
SE was added in Model 2. SE was a significant contributor
for Model 2 and was in the predicted direction (better SE
associated with fewer child hospitalizations; OR: 0.674).
The hypothesis that SE is a mediator was supported in two
ways. First, the change in depressive symptoms coefficient
when SE was added was significant in Model 2 (P = .069).

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Table 3 Unadjusted bivariate associations between key variables and risk-adjustment variables
Hospitalization Self-efficacy Consistently high depressive symptoms
Unadjusted P-value Unadjusted P-value Unadjusted P-value
odds ratio odds ratio odds ratio

Parenting self-efficacy 0.738 0.135 n/a n/a

Consistently high depressive symptoms 1.62 0.079* 0.391 0.001** n/a
Maternal age 1.02 0.534 1.02 0.567 0.912 0.078*
Race 0.783 0.521 0.980 0.955 0.596 0.405
Marital status 1.07 0.842 1.65 0.129 0.673 0.467
Very low income 1.10 0.640 0.763 0.173 1.20 0.510
Mother’s education 1.13 0.553 1.75 0.005** 0.335 0.001**
Mother’s employment 1.19 0.415 1.69 0.012** 1.13 0.703
Household density 0.592 0.029** 0.727 0.108 1.28 0.318
Second child 0.871 0.527 0.819 0.333 1.21 0.510
Lives with grandmother 0.875 0.513 0.775 0.195 1.18 0.547
Child’s sex 1.57 0.026** 1.49 0.041** 0.937 0.815
Child chronic condition 2.79 0.001** 0.957 0.846 1.10 0.763
Child’s birthweight 0.999 0.355 1.0004 0.049** 0.999 0.828
Child care by husband/boyfriend/father 0.865 0.535 0.877 0.553 0.972 0.928
* P \ 0.10, ** P \ 0.05

Table 4 Multivariate model results predicting child hospitalizations 1.2

Odds of child hospitalization

from birth to 24 months

1
Model 1: base model Model 2: base ? SE
0.8
Depressive symptoms 1.70 (1.05, 2.74) 1.57 (0.961, 2.55)
Self-efficacy (SE) 0.674 (0.469, 0.970) 0.6
90%
90% CI
90%
Odds ratios with 90% confidence intervals are shown 0.4
CI CI
Models were estimated using ordered logistic regression (categories:
0.2
0, 1, 2 ? hospitalizations). Consistently elevated depressive symp-
toms were measured by MHI-5 at 12 and 24 months. Maternal self-
0
efficacy (SE) was measured at 12 months and dichotomized at the very low low medium high
mean for this sample. Risk-adjustment variables listed in Table 1 (P<0.028; (reference; (P<0.039; (P<0.006;
4% of sample) 4% of sample) 40% of sample) 52% of sample)
were included in these models
Maternal self-efficacy

Second, SE was associated with child hospitalizations
while controlling for depressive symptoms, with lower SE
associated with more hospitalizations.
We also found support for the hypothesis that there is a
non-linear, inverse-U-shaped relationship between child
hospitalization and maternal SE. The highest rates of child
hospitalization were associated with the ‘‘low’’ SE category
(Fig. 1). The lower child hospitalization rates for the
‘‘medium’’ and ‘‘high’’ SE categories were consistent with
the primary hypothesis that lower SE is associated with more
child hospitalizations. However, mothers with ‘‘very low’’
SE had children with hospitalization rates that were similar
to mothers with ‘‘high’’ SE, which is consistent with the
hypothesis of a non-linear, inverse-U-shaped relationship.
When we included self-efficacy in the models in the
non-linear form (i.e., split into 4 categories) instead of as a
Fig. 1 Illustration of the non-linear relationship between child
hospitalizations and maternal self-efficacy. The low category is the
reference and represents the group with the highest rate of hospital-
ization. The percentage of the sample in each category and the
P-values are shown in parentheses. Note that the bars to the left
represent mothers with the least self-efficacy
continuous variable, the log-likelihood improved slightly
(P = .062), but the point estimates and significance for
depressive symptoms remained the same (P [ 0.10).
Because use of SE as a categorical variable did not
strengthen the model, we used SE as a continuous variable
in our mediation analysis.
An analogous analysis was conducted to test for a non-
linear relationship between maternal depressive symptoms
and child hospitalizations. A similar trend was found with
regard to point estimates for the 4 categories (increasing

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hospitalizations with increasing depressive symptoms, up
to a peak which was followed by decreasing hospitaliza-
tions). However, the point estimates for the 2 highest cat-
egories of depressive symptoms were not statistically
different and these 2 categories had very few observations
(13 total).
Discussion
Consistent with previous studies, we found that maternal
depressive symptoms were associated with increased child
hospitalizations. Low parenting self-efficacy was also sig-
nificantly related to increased child hospitalizations.
This is the first study to provide empirical evidence that
SE may serve as a mediator between maternal depressive
symptoms and child hospitalizations. Our findings suggest
that in clinical encounters with mothers, it may be helpful
for clinicians to assess maternal self-efficacy. Several
potential screening tools exist [47], including the 10-item
Maternal Efficacy Scale [22], which could provide valuable
information in a short time. A positive depressive symptom
screen might be an appropriate trigger for use of a par-
enting self-efficacy measure to identify mothers in need of
special help to improve their parenting effectiveness,
especially if they have children with medical vulnerability.
Our finding also suggests the potential value of inter-
ventions to improve self-efficacy, especially for depressed
mothers. A variety of interventions have been used to
improve self-efficacy for specific tasks [48]. For example,
group parent training sessions have been successful in
enhancing parenting SE among disadvantaged families
[49]. Findings from our study suggest that efforts targeting
the parenting skills of depressed low SES mothers may
improve their children’s health; such interventions may
also enhance the lives of vulnerable families, even if the
depression itself is not resolved.
A new finding of the study is the non-linear, inverse-U-
shaped relationship between SE and child hospitalizations.
The lower rates of child hospitalization for mothers with
the lowest self-efficacy support our hypothesis that these
mothers may not seek adequate healthcare for their chil-
dren. It is also possible that other adults, for example
grandmothers living in the same household, recognize that
these children are not being cared for appropriately by their
mothers and intervene by taking care of the child them-
selves and/or initiating healthcare visits, thus avoiding
unnecessary hospitalizations. Although we controlled for
the grandmother living in the same household and the care
provided by the husband/boyfriend/father, we did not have
data describing the involvement of these individuals in
healthcare decisions. The non-linear relationship should
be considered when designing interventions or future
1017
research. If mothers with the lowest levels of self-efficacy
are inappropriately avoiding healthcare for their children,
an intervention for them may initially increase child
healthcare utilization, but the ultimate outcome should be
improved parenting and better child outcomes.
We found only weak support for a non-linear relation-
ship between maternal depression and child hospitaliza-
tions. One possible explanation for this negative finding is
that few of the mothers were in the highest category of
depressive symptoms. In addition, there could be a more
complex non-linear interaction between self-efficacy and
depressive symptoms than we have the power to investi-
gate with these data.
Limitations
There are several limitations to this study. First, data used
in this study were collected in the early 1990 s in a single
metropolitan area. However, while access to healthcare and
practice patterns may be different today, the relationships
among depression, self-efficacy, and healthcare seeking
behaviors would not be expected to change over time. The
rate of hospitalization in this sample (0.24 per year) was
similar to another low-income population (0.21) from a
more recent study (2000–2001) [1], suggesting that utili-
zation may not have changed substantially. Second, our
measures of depressive symptoms and self-efficacy are not
commonly used today, but the measures remain valid. The
self-efficacy scores were limited to the upper half of the
range, which reduced the potential variation measured, but
there was reasonable spread across the range as detailed
earlier. In addition, we dichotomized the self-efficacy
measure 1.7 standard deviations below the highest score,
which minimized the influence of any potential ceiling
effect. Because these potential limitations to the self-
efficacy scale would have biased the results towards the
null, our significant findings might underestimate the
magnitude of the true association. Evidence of a slight
ceiling effect seen from the distribution of self-efficacy
scores in this low-income population, which is expected to
have lower self-efficacy than the general population [30],
suggests that this measure should be used with caution in
other populations. Third, our sample size may have been too
small to detect the relatively small effect sizes seen for
some of the relationships examined. Fourth, care should be
taken when generalizing the conclusions of this study to
other populations. It is likely that low-income mothers
interact with the healthcare system differently from middle-
class mothers. Nonetheless, this is a vulnerable population
with increased risks whose unmet needs deserve attention.
Although mediation has often been investigated with
cross-sectional data, it is conceptually most consistent to
utilize longitudinal analysis for mediation studies. Ideally
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we would measure depression first, at a later time measure
self-efficacy, and then at a third point measure healthcare
utilization. Unfortunately, this approach was not feasible,
given the data available, the episodic nature of depression,
and the need to collect healthcare utilization data over
some time period. We designed this study to address one
component of an interactive system; the findings allowed
the exploration of relationships and should contribute to the
generation of new hypotheses. Our results can guide and
justify future research, including replication of the study
using data collected longitudinally with repeated measures
of the key variables.
Conclusion
We conclude that in a population of low-income urban
mothers, self-efficacy is a likely mediator between mater-
nal depression and child hospitalizations and that low self-
efficacy is associated with more child hospitalizations.
Potential interventions to address parenting self-efficacy
along with depression treatment should be investigated.
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