Diversifying Electronic Cohort Research at UCSF

A community-engaged contest to select and support a diverse "eCohort" at UCSF

The Saving Our Ladies from Early Births and Reducing Stress (SOLARS) Cohort Study: Leveraging the Eureka Platform

Proposal Status: 

 

Summary:  Preterm birth is leading cause of death and disability in infants and children. Black and Latina women are at increased risk for preterm delivery compared to White women. While psychological stress has been shown to be associated with preterm birth, the mechanisms through which psychological stress causes preterm birth are unclear. The Saving Our Ladies from Early Births and Reducing Stress (SOLARS) study focuses on expanding our understanding of the relationship between psychological stress and preterm birth in 1,000 Black and Latina women in San Francisco, Oakland, and Fresno. The study has two primary research questions that examine the impact of individual, molecular, and social factors on psychological stress and preterm birth. The first question focuses on understanding patterns in all women in the study and the second focuses specifically on understanding why some women with high levels of psychological stress deliver preterm and some do not.

Introduction: More than one in ten Black and Latina pregnant women will have an infant born prematurely – that is, before 37 completed weeks of gestation. Infants born prematurely are at substantially increased risk for death within the first year of life and are more likely to have short- and long-term developmental and health challenges including, for example, intellectual delay, attention deficit hyperactivity disorder (ADHD), and asthma.

Rates of preterm birth in Black and Latina women have consistently been found to be 20 to 100% higher than in White women. Some data suggests that higher rates of preterm birth in women of color may be due to higher levels of stress – including higher levels of acute stress, accumulated lifetime exposure to stress, racism associated stress, and post-traumatic stress. Support for this explanation is driven by consistent findings showing an association between preterm birth and these different types of stress as measured by surveys, questionnaires and interviews.

Although studies have demonstrated specific links between multiple types of stress and preterm birth in women of color, what underlies this relationship remains unclear from a mechanistic point of view. For example, although cortisol is a key measure of biological stress, studies that have looked at the relationship between cortisol and preterm birth in women with both high and low levels of psychological stress have not observed a consistent link with preterm birth. The Saving Our Ladies from Early Births and Reducing Stress (SOLARS) study, funded by the UCSF California Preterm Birth initiative, is a prospective cohort study focused on expanding our understanding of the relationship between psychological stress, molecular signaling, and preterm birth in Black and Latina women in San Francisco, Oakland and Fresno.

Research questions: The SOLARS study focuses on two primary research aims including: 1) Evaluating whether individual, molecular, and social factors moderate or mediate the relationship between psychological stress and preterm birth in Black and Latina women (Aim 1); And, 2) Exploring the interrelationships of demographic, psychosocial, obstetric, and molecular risk and protective factors with preterm birth in Black and Latina women with high levels of psychological stress (Aim 2). Within Aim 1 we test three hypotheses: 1a, tests the hypotheses that social and individual risk and protective factors moderate the relationship between psychological stress and PTB;  Aim 1b, tests the hypothesis that individually-measured psychological resilience moderates the relationship between psychological stress and preterm birth; Aim 1c tests the hypothesis that molecular factors mediate the relationship between psychological stress and preterm birth. Whereas Aim 1 focuses on hypothesis testing, Aim 2 leverages advanced statistical techniques (i.e. machine learning) to determine whether or not there are factors within or across pregnancy that are associated with or predict  preterm birth in women with high levels of psychological stress. We believe that addressing these aims will lead to novel and actionable information that could eventually be translated into interventions for increasing gestational age and decreasing preterm birth in Black and Latina women in the geographies of focus and more broadly. In addition, we believe these efforts will contribute key data and biological resources for expanded and ongoing studies aimed at improving birth and developmental outcomes for women and children of color.

Addressing the SOLARS research aims requires intense work with participants and study partners throughout pregnancy and afterwards and includes the collection of survey data throughout pregnancy through the first year of life as well as biospecimens and hospital record data. Integration of the SOLARS study into the Eureka platform offers the opportunity to maximize engagement with women and study partners and we believe, could facilitate a more rapid cycling between discovery to interventions. In addition, use of the platform would offer the opportunity for developing nested studies that focus on other technologies including, for example, wearable activity and sleep tracking devices and contraction monitoring devices. In addition, leverage of the platform would eventually allow us to include more study sites across the United States and even worldwide as the effort progresses.

Study Sample: The SOLARS study will enroll 1,000 (500 Black and 500 Latina) women and their infants in San Francisco, Oakland and Fresno. The study pilot which aimed to assess methods for recruitment and retention and the acceptability of methods and measures among participants was conducted in March 2018-August 2018. We expect the full study to launch in the Fall of 2018 with enrollment extending over a three-year period (through 2021) and the full study extending through June 2023. Women are enrolled before 21 completed weeks of gestation at both UCSF and non-UCSF sites in all three geographies. All women included are self-identified as Black or Latina, are 18 years or older, are English and/or Spanish speaking, live or work full-time in one of the three geographies, and are expected to express a willingness to participate in all survey, biospecimen, and medical record review components of the study at all study time points in the prenatal period until the infant is one year of age. Women are not eligible for the study if they have active bipolar disorder or psychosis, if they are pregnant with a multiple gestation, if they are serving as birth surrogates, or if their pregnancy resulted from assisted reproductive technology.

Measurements: Participants complete online surveys and contribute biospecimens at up to 4 time points during pregnancy (11-14, 15-20, 24-26, 30-32). After birth, women complete surveys at 5-6 weeks, 6-months, and 12-months postpartum. Postpartum biospecimen collection is done at 5-6 weeks and 6-months. Hospital record review is done for all women from 1-year prior to pregnancy through 1-year after birth and for infants from birth through 12-months postpartum. Survey items focus on multiple components of psychological stress (e.g. childhood events, chronic strain, racism/discrimination), neighborhood and sociocultural factors (e.g. available healthcare, crime, poverty), individual factors (e.g. age, clinical factors, substance use/abuse), resiliency (e.g. mastery, self-efficacy, positive affect), and the current health status of the woman and infant (e.g. recent maternal and/or infant diagnoses). Required maternal biospecimen collection across time points include blood, urine and saliva. Molecular measures in biospecimens across time points include measures of the direct molecular stress response (cortisol and corticotropin-releasing hormone), measures of the immune response (cytokines, chemokines) and measures of placental health and growth (e.g. pregnancy-associated-protein-plasma protein A, nerve growth factor). We will also measure telomere length and target genetic markers (SNPs) with known associations to stress and/or preterm birth as well as lipids, proteins, metabolites and epigenetic signals in order to explore whether these pathways yield any useful information related to the link between stress and preterm birth. It is our belief that the Eureka platform would help facilitate all the survey measurement and hospital record review components of the study as well as online enrollment across sites and data visualization. We also believe that the Eureka platform might provide real-time specimen tracking capability across sites and might eventually provide a seamless way to share data with participants and partners.

Team: It is important to note that SOLARS study was designed from a reproductive justice perspective.This study was conceptualized, designed, and executed in a deeply engaged way with women of color serving in key leadership positions throughout the project. Project coordinators, graduate student researchers, and research assistants have been intentionally chosen to maximize the success of recruiting medically underserved women of color. We believe the integrity of the science and the quality of the data and their analyses are impacted by who, how, and why data are being collected.

The SOLARS team includes investigators across several schools and departments at UCSF and also includes investigators at UC Berkeley, UCSD, Stanford University, the University of Iowa, Cincinnati Children’s Hospital, and Fresno State University. The Primary Investigator on the study is Laura Jelliffe-Pawlowski, PhD – Director of Discovery and Precision Health within the UCSF California Preterm Birth Initiative. Dr. Jelliffe-Pawlowski has worked in the field of preterm birth for nearly two decades and is also the Mother of a daughter born preterm. Brittany Chambers, PhD, is one of two Co-Primary Investigators on the study and is an Assistant Professor in Epidemiology & Biostatistics at UCSF. Dr. Chambers’ research focuses on understanding the links between racism and preterm birth. Anu Gomez, PhD, is the other Co-Primary Investigator on the study and is an Assistant Professor in Sociology in the UC Berkeley School of Sociology. Dr. Gomez’ research focuses on understanding women’s contraception choices and on better understanding the reproductive experiences of Latina women.

Co-Investigators across UCSF include Dr. Larry Rand who is also the Primary Investigator of the UCSF California Preterm Birth Initiative, Drs. Monica McLemore, Elena Flowers, Kord Korber and Anatol Sucher in the School Nursing, Drs. Elizabeth Rogers and Matt Pantell in the Department of Pediatrics, Drs. Nancy Adler, Elissa Epel, and Jen Felder in the Department of Psychiatry, Dr. Nisha Parikh in the Department of Cardiology, and Dr. Charles McCulloch in the Department of Epidemiology & Biostatistics. This UCSF team works with closely with co-investigators at other institutions (Mike Snyder, PhD, at Stanford University, Christina Chambers, PhD at UCSD, Kelli Ryckman, PhD at the University of Iowa, Lou Muglia, MD, PhD, at Cincinnati Children’s Hospital, and Tania Pacheco, PhD at Fresno  State University). This transdisciplinary team also partners closely with women with lived experience and with community based organizations and clinics in San Francisco, Oakland and Fresno. The SOLARS team has a long-standing and ongoing relationship with the Community Advisory Board (CAB) of the California Preterm Birth Initiative. This CAB is composed mostly of Black and Latina women from San Francisco, Oakland and Fresno. All of the women on the CAB have either had a child with preterm birth or work closely with women at increased risk for preterm birth. These women have provided key input and suggestions at all phases of the SOLARS study and it is anticipated that they will remain involved as the study progresses. The study team also works closely with several organizations that serve low income women in one or more of the geographies of focus (e.g. Black Infant Health, La Clinica De La Raza). These partners assist with recruitment of women through their programs and provide feedback on study materials and methods.

Funding and Sustainability: The SOLARS study is funded by the UCSF California Preterm Birth Initiative. The UCSF Preterm Birth Initiative was funded by at $100 million gift from Marc and Lynn Benioff and Bill and Melinda Gates in 2015 and includes both a California arm and an East Africa arm. The California arm of the initiative will provide funding to the SOLARS project through fiscal year 2022-2023. Investigators are also seeking funding through the NIH and other entities to augment initiative costs and expand on the established research goals and infrastructure. It is also notable that the Eureka platform might eventually allow us to include women in Africa and other global locations in the study.

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Comments

Thanks for taking the time to submit. Your idea seems straightforward but could you share a 150-word plain language summary of how your aims connect?

Our selection committee has both UCSF and non-UCSF community-based members so a short accessible summary will make it easier for everyone to engage. 

Nice proposal and exciting project, Laura.  I agree that this project is a good fit for Eureka - as you know, we are working closely with you and your team to plan a Eureka portal for your project already.  I am sure that additional community engagement from our Diverse eCohorts project would enhance your work.

It looks like your focus is on Black and Latina women.  Would you be open to including Chinese women as well?  Would you be able to support Chinese language materials (assuming Eureka could support this)?

Hi Mark -- thanks for your input.

The SOLARS study focuses specifically on women at increased risk for preterm birth and was co-developed with Black and Latina women (our highest risk groups).

This is well thought out and in-depth proposal with much support. Congratulations as it is an important line of inquiry. A few thoughts/questions:

1) how do you see your project benefitting from community advisory given your established team of both researchers and community members? Happy to see the community advisor team and its work. Is this also a community participatory research project? 

2) can you shed light on how the women in the study would, and under what conditions, receive resoures/supports/interventions while the study is underway?  we would love to understand how you work out the ethical considerations for the project.

3) Curious as to how you see the Latina paradox working here - will you be examining generational differences in the Latin@ population?

4) what resources and/or compensation do/will study participants receive? it is a very intense-study....

5) Re: African American communities as you know, we have an increasingly number of Eritreans, Ethiopians, etc.. would be interesting to do a comparative study on pre-term given the cultural differences in the black community - including black Latin@s

Thank you for your comment and questions Dr. Gallegos-Castillo.


Re: 1) how do you see your project benefitting from community advisory given your established team of both researchers and community members? Happy to see the community advisor team and its work. Is this also a community participatory research project?


The SOLARS project has engaged community at multiple phases thus far. For example, women with lived experience participated in planning and prioritizing the question of focus, gave input on surveys and biospecimens to be collected, and women with lived experience reviewed and made suggestions with respect to study materials. Going forward we will be sharing results with women at all phases of the project in order to get their input on how results should be shared and disseminated but also to gain insight with respect to potential in-roads for risk communication and intervention. The project includes many key aspects of CBPR and includes not only women with lived experience but the community organizations and clinics that serve and support them. The study also includes leadership by women of color and by women who themselves were at risk for or delivered preterm.


Re: 2) can you shed light on how the women in the study would, and under what conditions, receive resources/supports/interventions while the study is underway? We would love to understand how you work out the ethical considerations for the project.

All women receive information packets at each visit with contact numbers and resource contacts related to mental health, substance abuse, and domestic violence services in Oakland/ Alameda County. Post-natal visit packet include additional materials and contacts for the Early Start Program for babies in Oakland/ Alameda County. Research assistants review the packets with women in detail at each visit.

Re: 3) Curious as to how you see the Latina paradox working here - will you be examining generational differences in the Latina population?

We capture if women were born in the United States or elsewhere for Black and Latina women. We believe this may be an important contributor to the patterns we observe both in terms of levels of reported psychological stress but potentially also as a mediator/moderator in measurement of stress and gestational age/ preterm birth associations.

Re: 4) What resources and/or compensation do/will study participants receive? it is a very intense-study

Women receive remuneration for their time in the form of gift cards for each visit. Remuneration is $30 per each prenatal visit and $40 per each postnatal visit plus an additional $10/visit if additional biospecimens beyond those required are collected.

Re: 5) Re: African American communities as you know, we have an increasingly number of Eritreans, Ethiopians, etc.. would be interesting to do a comparative study on pre-term given the cultural differences in the black community - including black Latinas.

Agreed. We are capturing not only US versus foreign born but also country of birth.

correction Re: #2 -- women in San Francisco and Fresno will receive packets specific to their county (the pilot was for Oakland only).

Hello. Thank you for those thoughtful responses. It seems like you have thought through your approach engaging community stakeholders. I just wanted to clarify that there are community advisors on the steering committee that will be weighing in on projects and working to support them. In what way do you think community advisory members on this steering committee could be helpful to your project? 

Thank you. I believe we would benefit tremendously from having input from the community advisors on the steering committee with respect to planned, ongoing, and potential in-roads with respect to recruitment, outreach and dissemination of results. We also hope to launch a more robust advertising effort aimed at increasing awareness around the work which needs input on tone, appearance and places where such outreach are deemed appropriate and to make sure that the materials are culturally appropriate and relevant to the women we are recruiting. Most important to us is that women see themselves in the work and feel represented and reflected from recruitment to results presentation.

Thank you for the proposal, and for focusing efforts and resources on answering these important research questions.  In referene to Dr Gallegos-Castillo's question around resources/ supports provided to patients, is there the potential for the community input offered via this partnership enhancing the resources/ supports offered to patients at all?  I understand you aren't necessarily testing interventions with this study, and still wondering if there is the potential for community input and partnerships to augment what women are offered, when participants are identified as having extreme levels of stress.

Thank you. We would welcome input and suggestions from community advisors on how best to address the needs of women who are highly stressed. We have materials with resources for women that are shared with all participants that could certainly be expanded.

This sounds like a great project. A couple of logistical questions.

1) The Diverse eCohorts support is for 1 year for development and recruitment assistance. Do you have funds to continue for the remaining 2 years? And if the Diverse eCohorts community partners can help with recruitment, is there the possibility of their continuing participation, if they wish, in your project?

2) What are the incentives for participants to join and stay in this intensive study?

 

Thank you for your comments.

Re: 1) The Diverse eCohorts support is for 1 year for development and recruitment assistance. Do you have funds to continue for the remaining 2 years? And if the Diverse eCohorts community partners can help with recruitment, is there the possibility of their continuing participation, if they wish, in your project?

Yes, the project is supported by the UCSF California Preterm Birth Initiative so will continue for at least 3-years and possibly longer. With respect to continued participation of community members after the first year -- there will absolutely be ongoing opportunities for participating in the project particularly around providing feedback on results and suggesting actionable in-roads for intervention.

2) What are the incentives for participants to join and stay in this intensive study?

Participants receive remuneration for their participation at each phase via gift cards. They also receive small gift bags with snack and beauty items as a thank you for their time.

 

Thank you for the detailed outline and the answers to the questions already posed. I have to say that the opening title "The Saving Our Ladies..." struck a particularly paternalistic/maternalistic note with me and I had to work hard to not write another dissertation on why the "saving" of Black and Brown strikes me this way. I will save it for an in person conversation, except to say that PTBi hosted a summit/conference on racism and pre-term birth where structural racism was discussed, it is disapointing to me that this is where the approach still seems structurally inequitable from the title. Knowing the work, I know that there is more than meets the title but the "whitestream" world of academia in to save the day is not what I think the researchers would want. 

Thank you so much for this input Monique. This is a study title that was generated by and for Black women. I know in that context the "saving our" part of this is different (rather than from the outside in) but I certianly know and see your point. This is something we discussed at some length early on with our CAB and they also really liked the name and it was kept. Still, we are moving from pilot to full study so it may be worth revisiting the discussion again. Thank you so much.

Given what you have written about the CAB I would think that a way to outline the work from the outset as community driven and community responsive could serve to support a different title that engages Black and Brown agency in this process and study. Thanks for listening.

he SOLARS team has a long-standing and ongoing relationship with the Community Advisory Board (CAB) of the California Preterm Birth Initiative. This CAB is composed mostly of Black and Latina women from San Francisco, Oakland and Fresno. All of the women on the CAB have either had a child with preterm birth or work closely with women at increased risk for preterm birth. These women have provided key input and suggestions at all phases of the SOLARS study and it is anticipated that they will remain involved as the study progresses.

 

Additionally given the feedback of the CAB - how much of what they say is integrated back into the work? And how are you all ensuring that accountability? 

Thank you again for your input. The CAB as well as Black and Brown women who have participated in previous work with the research team have provided input throughout the arc of the study and continue to do so. We meet with the CAB at roughly 6-month intervals and share progress on the study. 

In addition to my other comments, I do want to state that I strongly see the need for the work and want to see this work suceed, and to suceed I believe that the answers lie in social, environmental and structural raism and inequities and that they must be addressed in order to see these devastating numbers change.

Thank you again Monique. I agree with you completely. I have added some language into the team section now that clearly expresses our commitment to this work from a framing of reproductive justice.

Commenting is closed.