1. 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

2. 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.

3. 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.

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

5. Source: The National Center on SBS website

6. 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?

7. 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 YearPRAMS Pop.RespondentsWeighted R.R. 200412,0641,50675.5 200512,0131,42475.1 200611,7321,36072.5 2007118021,37272.1 200811,4671,29770.4

8. 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.

9. 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

10. 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) v10 software was used for statistical analyses to account for complex sample design of the survey.

11. Results

12. 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)

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

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

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

16. Prevalence of LKSBS by Race/Ethnicity P <.0001

17. Prevalence of LKSBS by Immigrant Status P <.0001

18. Prevalence of LKSBS by Maternal Age P <.0001

19. Prevalence of LKSBS by Maternal Education

20. P <.0001 Prevalence of LKSBS by Household Income

21. P <.0001 Prevalence of LKSBS by Marital Status

22. P = 0.0040 Prevalence of LKSBS by Parity

23. 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. Prevalence of LKSBS: Bivariate Analysis

24. 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.

25. 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 Assessing Independent Effects of Race/Ethnicity and Immigrant Status

26. Effects of Race/Ethnicity and Immigrant Status on LKSBS * AORs and 95% CIs were calculated after controlling for maternal age, education, household income, marital status, and parity. Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)* AOR95% 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 Immigrant Ref 3.9 Ref 2.7-5.6

27. Effects of Race/Ethnicity on LKSBS: Stratified by Immigrant Status * AORs and 95% CIs were calculated after controlling for maternal age, education, household income, marital status, and parity. Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)* Non-Immigrants (n=5,046) AOR (95% CI) Immigrants (n=1,898) AOR (95% CI) NH-White NH-Black NH-Asian/PI Hispanic Ref 2.6 (1.3-5.2) 2.4 (0.7-7.6) 3.1 (1.7-5.6) Ref 2.5 (1.3-4.9) 2.9 (1.4-5.9) 1.2 (0.6-2.1)

28. 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 Assessing Joint Effects of Race/Ethnicity and Immigrant Status

29. Joint Effects of Race/Ethnicity and Immigrant Status on LKSBS * AORs and 95% CIs were calculated after controlling for maternal age, education, household income, marital status, and parity. Adjusted Odds Ratios (AORs) and 95% Confidence Intervals (CIs)* AOR95% CI 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 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 Indep. Effects: Either Minority OR Immigrant Joint Effects: Both Minority AND Immigrant

30. Joint Effects of NH-Back & Immigrant: –Expected Odds Ratio = 2.5+5.0-1.0 = 6.5 –Observed Odds Ratio = 13.6 Joint Effects of NH-Asian/PI & Immigrant: –Expected Odds Ratio = 2.3+5.0-1.0 = 6.3 –Observed Odds Ratio = 14.7 Joint Effects of Hispanic & Immigrant: –Expected Odds Ratio = 3.0+5.0­1.0 = 7.0 –Observed Odds Ratio = 6.5 Assessing Interaction: Additive Scale Positive Additive Interaction No Additive Interaction

31. Joint Effects of NH-Back & Immigrant: –Expected Odds Ratio = 2.5*5.0 = 12.5 –Observed Odds Ratio = 13.6 Joint Effects of NH-Asian/PI & Immigrant: –Expected Odds Ratio = 2.3*5.0 = 11.5 –Observed Odds Ratio = 14.7 Joint Effects of Hispanic & Immigrant: –Expected Odds Ratio = 3.0*5.0 = 15.0 –Observed Odds Ratio = 6.5 Assessing Interaction: Multiplicative Scale No Multiplicative Interaction Negative Multiplicative Interaction Positive Multiplicative Interaction ???

32. 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).

33. 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.

34. 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)

35. 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.

36. THANK YOU! Contact Information: Hanna Kim, PhD: Hanna.Kim@health.ri.gov