Psychometric Properties of the Prenatal Opioid Use Perceived Stigma Scale and Its Use in Prenatal Care

Abstract

Objective:

To examine the psychometric properties of the Prenatal Opioid Use Perceived Stigma (POPS) scale and to assess the relationship of POPS scores to adequate prenatal care.

Design:

Prospective cohort study.

Setting:

Medical centers in Alabama, Ohio, and Pennsylvania (N = 4).

Participants:

Women (N = 127) who took opioids during pregnancy and whose infants participated in the Outcomes of Babies with Opioid Exposure (OBOE) Study.

Methods:

Participants reported their perceptions of stigma during pregnancy by responding to the eight items on the POPS scale. We evaluated the instrument’s internal consistency reliability (Cronbach’s alpha), structural validity (factor analysis), and convergent validity (relationship with measures of similar constructs). In addition, to assess construct validity, we used logistic regression to examine the relationship of POPS scores to the receipt of adequate prenatal care.

Results:

The internal consistency of the POPS scale was high (Cronbach’s alpha = 0.88), and all item-total correlations were greater than .50. The factor analysis confirmed that the items cluster into one factor. Participants who reported greater perceived stigma toward substance users and everyday discrimination in medical settings had higher POPS scores, which supported the convergent validity of the scale. POPS scores were significantly associated with not receiving adequate prenatal care (adjusted odds ratio [AOR] (95% CI) = 1.47 (1.19, 1.83), p < 0.001).

Conclusion:

The psychometric testing of the POPS scale provided initial support for the reliability and validity of the instrument. It may be a useful tool with which to assess perceived stigma among women who take opioids, a potential barrier to seeking health care during pregnancy.

Precis:

The newly developed Prenatal Opioid Use Perceived Stigma scale demonstrated good psychometric properties and can be used to assess a potential barrier to prenatal care.

Opioid use among pregnant women has increased substantially in the past decade. In 2010, the rate of maternal opioid-related diagnoses was 3.5 per 1,000 birth hospitalizations while in 2017, the rate was 8.2 per 1,000 birth hospitalizations (Hirai et al., 2021). Opioid use during pregnancy frequently results in neonatal abstinence syndrome (NAS) in exposed newborns. Following a similar trajectory to use of opioids during pregnancy, the incidence of NAS increased from 4.0 per 1,000 birth hospitalizations in 2010 to 7.3 per 1,000 birth hospitalizations in 2017 (Hirai et al., 2021).

Historically, health care providers’ perceptions and judgments of those with opioid use disorder (OUD) followed an established pattern of stigma and belief that individuals with OUD are more dangerous than the general population (Kennedy-Hendricks et al., 2016). Feelings of judgment and stigma experienced by pregnant women interfere with the establishment of trust with health care providers and can potentially affect care (Cleveland & Bonugli, 2014). Furthermore, fear of a diagnosis, further judgement, and involvement of child protective services were conceptualized as internalized stigma in expectant mothers (Syversten et al., 2021).

Pregnancy can be considered a window of opportunity to encourage health and well-being among women with OUD (Goodman et al., 2020). Although prenatal care is a significant contributor to decreasing the negative effects of substance use on the developing fetus, state child abuse and mandatory reporting policies and fear of discrimination and loss of custody are associated with delays in prenatal care and treatment (Rosenthal & Baxter, 2019). Syversten et al. (2021) found that structural and enacted stigma associated with providers’ behaviors compromised initiation, engagement, and retention in treatment programs and affected access to quality health care for women with histories of opioid misuse. Among health care providers, fear and stigma related to pregnant women with OUD leads to missed opportunities to provide comprehensive care, particularly the ability to integrate substance use therapists and related care providers into the multidisciplinary teams, including obstetricians/gynecologists, neonatologists, pediatricians, nurses, lactation consultants, social workers, that interact with women during pregnancy.

Available scales to measure stigma related to substance use are not specific to the perinatal period or to opioids. The Substance Use Stigma Mechanisms Scale (Smith et al., 2016) is used to measure stigma as perceived by individuals who use substances. Luoma et al. (2010) modified a scale to measure perceived stigma toward mental illness created by Link et al. (1997) to develop the Perceived Stigma of Substance Abuse Scale (PSAS). Most recently, Shuman et al. (2022) contemporized the Attitudes About Drug Abuse in Pregnancy questionnaire (Selleck & Redding, 1998) to reflect current terminology in the Modified Attitudes About Drug Use in Pregnancy Scale. This scale was designed to be completed by nurses who interact with women during pregnancy and the perinatal period.

We developed the Prenatal Opioid Use Perceived Stigma (POPS) scale to assess perceived stigma among women who took opioids during pregnancy after a review of the literature rendered no such measures. We defined perceived stigma as beliefs that members of a stigmatized group have about stigmatizing attitudes and actions in society, a definition that is consistent with past research (Link, 1997; Luoma et al., 2010). While designed as a brief one-factor scale, we developed items to address these three aspects of stigma among this population to ensure content validity of the scale: delays in care, communication with providers, and patient-provider interaction. The POPS scale items were independently reviewed by a survey methodologist to ensure they reflected best practices in survey design. The scale was administered to the mothers of opioid-exposed newborns enrolled in the Outcomes of Babies with Opioid Exposure (OBOE) Study shortly after birth during the birth hospitalization or at the 0 to 1-month study visit. We assessed the psychometric properties of the POPS scale using these data.

Methods

Study Design

The Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW) OBOE Study is a prospective longitudinal cohort study of outcomes of infants with antenatal opioid exposure and controls (unexposed infants) from birth to 2 years of age (ClinicalTrials.gov NCT04149509). In addition to the evaluation of the effect of antenatal opioid exposure on child outcomes, the study was designed to evaluate whether maternal, family, home, and community factors modify developmental trajectories during this critical period. During the first OBOE Study visit, birth mothers of opioid exposed infants responded to the POPS scale and additional questions about demographics and their medical, social, and substance use histories.

Through a single-Institutional Review Board at Cincinnati Children’s Hospital Medical Center, the OBOE Study clinical sites, neuroimaging core, and data coordinating center received approval for human subjects’ research activities, and informed consent was obtained for all participants. The study protocol is described elsewhere in detail (Bann et al., 2022).

Participants

Participants included 127 mothers and their newborns who were exposed to opioids if they were born at or after 37 weeks gestation and were exposed to opioids in the second or third trimester. Infants were excluded if their mothers reported heavy alcohol use during pregnancy (eight or more alcoholic drinks per week). In addition, we used the following exclusion criteria for infants: known chromosomal or congenital anomalies with the potential to affect the central nervous system, 5-minute Apgar score of less than 5, any requirement for positive pressure ventilation in the NICU, inability to return for outpatient MRI or follow-up, and intrauterine growth restriction below the third percentile. Demographic characteristics of the sample participants are shown in Table 1.

Table 1:

Demographic Characteristics of the Sample N = 127

Characteristic	n (%)	POPS Scale Score
		Mean (SD)	p
Maternal age (years)
< 25	16 (13)	2.94 (2.43)	0.414
25–29	40 (32)	1.70 (2.41)
30–34	47 (37)	2.34 (2.82)
≥ 35	23 (18)	2.26 (2.65)
Race and ethnicity
Non-Hispanic White	112 (88)	2.21 (2.63)	0.927
Non-Hispanic Black	14 (11)	1.93 (2.64)
Hispanic	1 (1)	2.00 (N/A)
Marital status
Married	16 (13)	3.25 (3.07)	0.109
Not married	105 (83)	2.11 (2.55)
Education
Less than high school	23 (18)	1.65 (2.52)	0.243
High school diploma	31 (24)	2.19 (2.46)
More than high school	30 (24)	2.83 (2.63)
Public insurance
Yes	112 (88)	2.27 (2.65)	0.069
No	12 (9)	0.83 (1.59)
Parity
1	23 (18)	2.52 (2.63)	0.492
2+	104 (82)	2.11 (2.61)

Note. POPS = Prenatal Opioid Use Perceived Stigma

Missing data: maternal age (n = 1), marital status (n = 6), education (n = 43), and public insurance (n = 3).

Measures

Stigma and Discrimination

The POPS scale is used to assess perceptions of stigma in health care settings among pregnant women with OUD. The eight-item measure is intentionally brief to minimize burden on the respondent and allow for use in clinical or community settings when time is limited. Table 2 shows that the scale includes two items about delays in care, two items about communication with providers, and four items about patient-provider interactions. Scale scores are calculated by the number of yes responses to the items (e.g., 1 point per yes response). Total scale score values range from 0 to 8.

Table 2.

Frequency of Responses and Reliability and Validity Estimates of the Prenatal Opioid Use Perceived Stigma (POPS) Scale

POPS Scale Item	Yes Response n (%)	Item-Total Correlation	Cronbach Alpha if Item Deleted	Factor Loading
Delays in care
1. Delay getting health care because you were worried about how your health care providers would treat you if they found out about your opioid use?	41 (32)	0.68	0.86	0.86
2. Delay getting health care because you were worried that you would have to take a drug test?	36 (28)	0.57	0.88	0.71
Communication with providers
3. Feel that you could not talk to your health care providers about your opioid use?*	37 (29)	0.55	0.88	0.77
4. Try to avoid talking to your health care providers about your opioid use because you were worried they would judge you?	48 (38)	0.70	0.86	0.90
Patient-provider interaction
5. Feel your health care providers treated you differently than other patients because of your opioid use?	40 (32)	0.64	0.87	0.91
6. Your health care providers make you think you wouldn’t be a good mother because of your opioid use?	22 (17)	0.71	0.86	0.98
7. Your health care providers make you feel like you couldn’t be trusted to make good choices because of your opioid use?	33 (26)	0.71	0.86	0.92
8. Your health care providers blame you for putting your pregnancy at risk because of your opioid use?	20 (16)	0.66	0.87	0.93

Note. The following question was the prompt for response: While you were pregnant, did you/did… Cronbach’s alpha for overall scale is 0.88. Model fit indices for 1-factor confirmatory factor analysis are: CFI = 0.99, TLI = 0.98, SRMR = 0.08, and RMSEA (90% CI)=0.10 (0.06, 0.14).

^*This item is reverse coded for this analysis and “not” added to the wording in the table for clarity. Original item wording on the scale is “Feel that you could talk to your health care providers about your opioid use?”

We asked participants additional questions on similar constructs to assess convergent validity. We administered the seven-item Everyday Discrimination in Medical Settings scale (Peek et al., 2011) with a slight modification to refer to health care during pregnancy. We included three items from the scale developed by Luoma and colleagues (2010) to assess perceived stigma toward substance users (Table 3).

Table 3.

Means and Standard Deviations of Prenatal Opioid Use Perceived Stigma (POPS) Scale Scores by Responses to Similar Measures

Scale Items	POPS Score by Item Response M (SD)
Everyday Discrimination in Medical Settings	Never	Rarely	Sometimes/Most of time/Always	p
During your pregnancy:
1. You were treated with less courtesy than other people	1.34 (2.41)	2.96 (2.19)	3.48 (2.71)	< 0.001
2. You were treated with less respect than other people	1.38 (2.27)	3.35 (2.53)	3.27 (2.79)	<0.001
3. You received poorer service than others.	1.82 (2.52)	2.79 (2.64)	3.47 (2.72)	0.038
4. A doctor or nurse acted as if he or she thought you are not smart.	1.51 (2.25)	3.20 (2.96)	3.39 (2.68)	< 0.001
5. A doctor or nurse acted as if he or she was afraid of you.	2.08 (2.53)	1.25 (1.89)	7.33 (0.58)	0.002
6. A doctor or nurse acted as if he or she was better than you.	1.18 (1.97)	3.50 (2.87)	3.87 (2.70)	< 0.001
7. You felt like a doctor or nurse was not listening to what you were saying.	1.28 (2.10)	2.37 (2.63)	3.41 (2.80)	< 0.001
Perceived stigma toward substance users	Strongly disagree/Disagree	Neither agree nor disagree	Strongly agree/Agree	p
1. Most people would willingly accept someone who has been treated for substance use as a close friend	2.85 (2.62)	1.85 (2.56)	1.73 (2.57)	0.092
2. Most people think less of a person who has been in treatment for substance use	1.15 (2.48)	1.13 (2.07)	2.73 (2.64)	0.004
3. Most people believe that someone who has been treated for substance use is just as trustworthy as the average citizen	2.84 (2.77)	0.70 (1.36)	1.35 (2.16)	<0.001

Prenatal Care

We defined adequate prenatal care as three or more visits and starting care before the third trimester. For the logistic regression analyses, we modeled risk for not having met these criteria (i.e., not having received adequate prenatal care).

Data Analyses

We conducted several item- and scale-level analyses to examine the psychometric properties of the POPS scale. We calculated descriptive statistics for each item, including the distribution of responses and item-total correlations. We fit two-parameter logistic item response theory (IRT) models to evaluate item discrimination (slopes) and placement along the stigma continuum (thresholds).

We assessed the internal consistency reliability of the scale using a Cronbach’s alpha coefficient and by examining the item-total correlations. We considered an alpha of 0.70 or higher and item-total correlations of 0.30 or higher as indicators of good internal consistency reliability. To assess structural validity, we conducted a confirmatory factor analysis (CFA) to verify the hypothesized single factor structure of the items. We used values of the comparative fit index (CFI), Tucker-Lewis fit index (TLI), standardized root mean square residual (SRMR), and root mean square error of approximation (RMSEA) to determine fit of the CFA model. We considered values of 0.95 or higher for CFI and TLI as indicators of a good model fit (Hu & Bentler, 1999) and values of 0.08 or lower to indicate acceptable model fit based on the SRMR (Hu & Bentler, 1999) and RMSEA (Browne & Cudeck, 1993). We evaluated the convergent validity of the scale by examining the relationship between POPS scale scores and measures of similar constructs. Specifically, we conducted analyses of variance (ANOVAs) to compare the mean POPS scores by responses to items on Everyday Discrimination in Medical Settings scale and the three items from the Perceived Stigma toward Substance Users scale. We hypothesized that participants who reported discrimination or perceived stigma on these similar measures would have higher scores on the POPS scale.

Furthermore, to assess construct validity of the scale, we fit logistic regression models to examine the relationship between POPS scale scores and receiving adequate prenatal care. In particular, we expected that women who reported delays in care due to anticipated stigma would be more likely to not have received adequate prenatal care. Each model included the following demographic characteristics as control variables: maternal age, race/ethnicity, marital status, education, public insurance, and parity. We selected these characteristics as control variables based on previous research indicating variation in prenatal care utilization by social determinants of health and pregnancy characteristics (e.g., Green, 2018). In addition to the analyses of continuous scale scores, similar logistic regression models tested the relationship between prenatal care and reporting any stigma (i.e., any yes response) based on the overall scale and individual items.

The analyses included participants who responded to at least one of the POPS scale items. Item 3 was reverse coded for the analyses, so that higher scores indicated more stigma for all items. For the regression model, we imputed missing data for demographic variables using hot deck imputation (Andridge & Little, 2010). The regression model was also fit without imputation of missing values as a sensitivity analysis. We conducted descriptive statistics and regression analyses using SAS version 9.3, factor analyses using Mplus version 8.6 (Muthén & Muthén, 1998–2017), and IRT analyses using IRTPRO version 4.1 (Cai et al., 2011).

Results

Most participants in the sample were between the ages of 25 and 34 (69%) and identified as non-Hispanic, White (88%; Table 1). Eighty-three percent were not married and 18% were nulliparous. Most (88%) were on public insurance and 24% had more than a high school education.

Table 2 shows the distribution of item responses. Participants were most likely to report that they avoided talking to providers about their opioid use because of worries about being judged (item 4) (38%). In addition, nearly one-third of participants (32%) reported that they delayed getting prenatal care because they were worried about how providers would treat them if they were aware of their opioid use (item 1). When they did interact with their providers, they did feel they were treated differently because of their opioid use (item 5) (32%).

The factor analysis confirmed that the items cluster into one factor (CFI = 0.99, TLI = 0.98, SRMR = 0.08, and RMSEA (90% CI) = 0.10 (0.06, 0.14)) with all fit indices except RMSEA meeting the criteria for good or acceptable fit. The RMSEA was slightly higher than the acceptable criterion; however, Shi and colleagues (2018) found that RMSEA tends to be upwardly biased (indicating worse fit) with small sample sizes. The overall POPS scale demonstrated good internal consistency reliability with a Cronbach’s alpha of 0.88. None of the alphas if item deleted exceeded the overall alpha, supporting the contributions of the items to the overall scale. All items demonstrated good discrimination with item-total correlations ranging from 0.55 to 0.71 (Table 2) and steep IRT slopes (Figure 1). Mean scale scores did not differ significantly by demographic characteristics (Table 1).

Figure 1:

Item Characteristic Curves for Prenatal Opioid Use Perceived Stigma (POPS) Scale Items

Based on the ANOVAs, the scale demonstrated the expected pattern of relationships with similar measures, supporting the construct validity of the POPS scale (Table 3). Generally, participants who reported greater perceived stigma toward substance users and everyday discrimination in medical settings had higher POPS scores. For example, on item 1 of the Everyday Discrimination in Medical Settings scale, mean stigma scores were significantly higher for those reporting that they were more often treated with less courtesy than other people: never (1.34), rarely (2.96), and sometimes or more frequently (3.48) (p < 0.001).

POPS scores were significantly associated with not receiving adequate prenatal care (adjusted odds ratio [AOR] (95% CI) = 1.47 (1.19, 1.83), p < 0.001). Participants reporting greater stigma were more likely to have not received adequate care during their pregnancies. We found similar results when repeating the logistic regression analysis without imputing missing values for demographic variables (AOR (95% CI) = 1.46 (1.06, 2.00), p = 0.020).

We also explored whether specific aspects of stigma (delays in care, communication with providers, and patient-provider interaction) were related to receipt of adequate prenatal care after controlling for demographic characteristics. As shown in Figure 2, those who reported any stigma had 19 times the odds of not having received adequate prenatal care (AOR (95% CI) = 19.23 (3.63, 102.02), p < 0.001). Communication with providers was most strongly related to prenatal care. Those who reported any stigma related to communicating with their providers had nearly 9 times the odds of not receiving adequate prenatal care (AOR (95% CI) = 8.79 (2.51, 30.78), p < 0.001).

Figure 2:

Adjusted Odds Ratios and 95% CI of Not Receiving Adequate Prenatal Care by Responses to Prenatal Opioid Use Perceived Stigma (POPS) Scale

Note. AOR = adjusted odds ratio. Odds ratios are adjusted for maternal age, race/ethnicity, education, marital status, public insurance, and parity.

Discussion

The psychometric testing provided initial support for the validity and reliability of the POPS scale. Our findings demonstrated that the newly developed POPS scale successfully leverages eight items to measure perceived stigma related to delays in care, communication with providers, and patient-provider interactions. Our psychometric analyses confirmed single factor clustering, strong item-level discrimination, high internal consistency, and good construct validity, supporting the continued use of the POPS scale for measurement of perceived stigma among pregnant women who take opioids.

Furthermore, we found that perceived stigma was significantly related to inadequate receipt of prenatal care. Birth mothers who shared experiencing stigma in healthcare settings related to the communication patterns with providers had upwards of ten times the odds of not receiving adequate prenatal care as compared to those who did not report the same degree of perceived stigma. These findings further support the notion that stigma continues to be a chronic experience for those with substance use disorders and for individuals accessing care during their pregnancies.

Addressing perceived stigma must become a priority to improve comprehensive access to and engagement in care, especially in those who are pregnant. Validated measures to assess opioid-related perceived stigma, specifically during the prenatal period, are essential to evaluating interventions to ameliorate the initiation, engagement, and retention in treatment programs. This approach is crucial to curtailing the number of infants experiencing neonatal opioid withdrawal syndrome.

Limitations and Next Steps

Findings should be considered in light of limitations and opportunities for future work. The main objectives of the larger OBOE Study were to determine the impact of antenatal opioid exposure on infant development during the first two years of life and to identify family, home, and community factors that modify those developmental trajectories. Although assessing perceived stigma is an important factor to consider in pregnant people accessing an OUD treatment program and prenatal care, it was not the main objective of the OBOE Study. Therefore, a small number of mother-specific measures were included in the study, limiting the scope of the evaluation. Additional studies specifically targeting and evaluating barriers of access to care for these individuals utilizing the POPS scale are necessary to further understand the broader contextualization and additional factors that may contribute to stigma and compromised care.

Infants enrolled in the OBOE Study were term, medically stable, and had families who had the ability and expressed willingness to return for outpatient MRI and follow-up visits. This resulted in a smaller sample size than if mothers of all infants with antenatal opioid exposure at the clinical sites were enrolled in the study. It is also possible that mothers of infants not meeting the inclusion criteria for the study may have reported stigma levels higher than those enrolled in the study. In addition, while several efforts are ongoing to increase participant racial and ethnic diversity for the study, the current study sample was predominantly non-Hispanic, White. Future studies are needed to evaluate the performance of the POPS scale among a more diverse population.

Conclusion

The POPS scale is a brief, easy-to-administer instrument for assessing perceived stigma among women who take opioids, a potential barrier to seeking health care during pregnancy. The scale demonstrated good initial reliability and validity in the sample, and the study findings indicate that greater perceived stigma as measured by the POPS scale is associated with diminished likelihood of receiving adequate prenatal care. The scale could potentially be used as a tool for monitoring ongoing health care initiatives aimed at improving communication and relationship building between health care providers and those who are pregnant with OUDs. It provides valuable insight into experiences of this unique population, which could be helpful in future training of health care providers in order to improve outcomes of pregnant women with OUD and their infants.