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Protective Factors Using 
the Life Course Perspective 
in Maternal and Child 
Health  
A Community-Based Participatory Research Approach 

ABRAHAM A. SALINAS-MIRANDA, LINDSEY M. KING, HAMISU M. SALIHU, RONEÉ E. 
WILSON, SUSAN NASH, SARAH L. COLLINS, ESTRELLITA “LO” BERRY, DEBORAH 
AUSTIN, KENNETH SCARBOROUGH, EVANGELINE BEST, LILLIAN COX, GEORGETTE 
KING, CARRIE HEPBURN, CONCHITA BURPEE, RICHARD BRISCOE, JULIE BALDWIN 

ABSTRACT 

The life course perspective (LCP), a valuable theoretical framework for investigating 
racial disparities in birth outcomes, examines the cumulative exposure of risk and 
protective factors throughout the life span. Although risk and protective exposures 
are equally vital to health, most studies have focused solely on the risk factor 
exposures faced by vulnerable populations. In clear contrast to the traditional 
public health approach, which emphasizes a deficit model, strengths-based 
approaches focus on protective factors and fostering resilience.   These approaches 
view communities as valuable assets that have the capacity to fully engage 
themselves and their residents to achieve optimal health. Participatory action 
research methods are well suited to apply a strengths-based approach to 
understand health disparities. Our study aimed to explore maternal and child 
health protective factors from community residents’ perspective. A group of 
researchers, including active members in the community with a long history of 
grassroots development work, conducted ten community-based participatory focus 
groups with community residents in Tampa, FL, using the LCP framework. A total 
of 78 residents participated in ten focus groups. Perceived protective factors during 
pregnancy included self-esteem, spirituality, pregnancy support, good nutrition, 
prenatal care, and community resources. Protective factors for non-pregnant 
women were self-esteem, spirituality, social support, health literacy, community 
support and community resources, and societal factors. For children and 
adolescents, relevant protective factors were self-esteem, positive role models, 
nutrition and physical activity, and community support. The identified factors are 
community assets or strengths that mitigate or eliminate maternal and child health 
risks in families and communities residing in low-income neighborhoods, which 
must be considered in developing effective maternal and child health interventions. 

Keywords: Community-based participatory research (CBPR), maternal and 
child health, life course perspective, protective factors, qualitative research 

Authors 

ABRAHAM A. SALINAS-
MIRANDA 
University of South Florida 

LINDSEY M. KING  
University of Florida 

HAMISU M. SALIHU 
Baylor College of Medicine  

RONEÉ E. WILSON 
University of South Florida 

SUSAN NASH  
Baylor College of Medicine 

SARAH L. COLLINS 
University of Florida 

ESTRELLITA “LO” BERRY 
REACHUP Inc. 

DEBORAH AUSTIN 
REACHUP Inc. 

KENNETH SCARBOROUGH 
REACHUP Inc. 

EVANGELINE BEST 
REACHUP Community 
Advisory Board 

LILLIAN COX  
REACHUP Community 
Advisory Board 

GEORGETTE KING 
REACHUP Community 
Advisory Board 

CARRIE HEPBURN 
REACHUP Community 
Advisory Board 

CONCHITA BURPEE 
REACHUP Community 
Advisory Board 

RICHARD BRISCOE 
REACHUP Community 
Advisory Board 

JULIE B ALDWIN 
Northern Arizona University 69 VOL. 1, ISSUE 3



INTRODUCTION 

The disparity in birth outcomes between Black 
and White Americans is one of the most persistent 
and striking health disparities in the U.S. Black 
infants are twice as likely to die within the first 
year of life and have higher rates of low birth 
weight and preterm birth than White counterparts 
(Hauck et al., 2011; Salihu et al., 2011; Tucker et 
al., 2007). To explain this disparity, researchers 
are exploring relationships between healthcare, 
social, environmental, bio-behavioral, economic, 
and structural factors over the life course (e.g., 
racism) and across generations (Lu & Halfon, 
2003). In this context, the life course perspective 
(LCP) has been proposed as an overarching 
theoretical framework to guide multidisciplinary 
research in racial/ethnic disparities in birth 
outcomes (Lu & Halfon, 2003). 

The LCP explains how risk and protective factors 
at the individual, relationship, community, and 
societal levels influence health over the life span 
(Centers for Disease Control Prevention [CDCP], 
2011; Hellserstedt, 2013). The LCP suggests that 
conditions a mother is born into and grows up in, 
as well as her pregnancy circumstances, are all 
important for reproductive success and future 
health (Lu & Halfon, 2003; Pies et al., 2012). In 
this context, G. H. Elder (1998) proposes the 
principles of life course theory, which includes: 
(1) Life-Span Development, which explains that
both human development and aging are lifelong
continuous processes; (2) Human Agency, which
states that persons as individual agents shape
their lives through the choices and actions they
take but within the constraints and opportunities
of their socio-historical circumstances; (3) Time
and Place, which highlights the influence of the
historical times and places on the life trajectories
of individuals and communities; (4) Timing,
which focuses on the consequences of life
transitions, events, and behavioral patterns that
vary according to their timing in a person’s life;
(5) Linked or Interconnected Lives, which
illustrates that human lives are interdependent
and that socio-historical influences happen within
a network of shared relationships. Through these

principles, life course research emphasizes the 
study of cumulative exposures of protective and 
risk factors that contribute to good or poor health 
trajectories (Elder & Giele, 2009; Hellerstedt, 
2013; Lu et al., 2010). Studies have suggested that 
Black women residing in the U.S. may be exposed 
to fewer protective and more risk factors 
throughout their life course than White women 
(Lu & Halfon, 2003).  

Although risk and protective exposures are 
equally vital to optimal health, most studies have 
focused solely on the risk factor exposures faced 
by vulnerable populations (Salinas-Miranda et al., 
2017). For example, there is evidence that Black 
women are more likely to be exposed to 
discrimination and more social stressors (Nuru-
Jeter et al., 2009). Moreover, the disparities 
persist even for Black women who are highly 
educated and with higher incomes, suggesting 
that American women living in the same 
socioeconomic category may not have the same 
life experiences (Lu & Halfon, 2003). Racism is 
also a factor that exerts its influence over the life 
course (Nuru-Jeter et al., 2009), affecting adults 
and children. In contrast, the evidence on 
protective factors specific to maternal and child 
health remain scant and loosely defined. Some 
hypothesized protective factors include resiliency 
(stress-coping mechanisms), healthy 
relationships, and health-promoting policies 
(Hellerstedt, 2013).  

The traditional public health approach 
emphasized a deficit model which viewed 
communities as problems that need to be fixed 
(Hellerstedt, 2013). In clear contrast to such 
traditional views, strengths-based approaches, 
such as community resiliency, appreciative 
inquiry, and asset-based mapping analyses, focus 
on community protective factors that foster 
resilience (Zimmerman, 2013). Such positive 
perspectives represent a paradigm shift that views 
communities as valuable assets that have the 
capacity to fully engage themselves and their 
residents to achieve optimal health (Zimmerman, 
2013). In line with the current asset-based 
approaches in maternal and child health, our 

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study adds information on specific protective 
factors that are relevant for disadvantaged 
communities of color (Friedeli, 2012; Lightfoot, 
McCleary, & Lum, 2014; Morgan & Ziglio, 2007; 
Schooley & Morales 2007). Other authors have 
used strengths-based approaches, but studies that 
capture low-income neighborhood residents' 
perspectives are less common. Participatory 
action research (PAR) methods are well-suited to 
apply a strengths-based approach to understand 
disparities (Minkler et al., 2003) and capture the 
unique perspective of the community members 
themselves in explaining the protective factors 
that lead to optimal health. Maternal and child 
health programs could benefit from a greater 
focus on community-centered and community-
driven approaches to understanding disparities in 
MCH. The health care field needs to integrate PAR 
into community health needs assessments and 
make informed decisions based on the community 
perspective (Wallerstein & Duran, 2006). 
Research using the LCP can be significantly 
enhanced through the use of community-based 
participatory research (CBPR), a strategy that 
utilizes the intimate participation of community 
residents in every decision-making phase of the 
project (Blumenthal, 2011; Israel, 2005; Minkler 
& Wallerstein, 2003; Schulz et al., 2002; 
Wallerstein & Duran, 2006). CBPR is a useful 
technique for collecting the community 
perspective and results in culturally-tailored 
public health interventions that are more 
pertinent to the lived experiences of community 
residents (Blumenthal, 2011; Israel, 2005; 
Minkler & Wallerstein, 2003; Schulz et al., 2002; 
Wallerstein & Duran, 2006). Therefore, using the 
CBPR approach to frame the inquiry and the LCP 
as the guiding theoretical framework, this study 
explored maternal and child health protective 
factors from community residents’ perspectives. 

MATERIAL AND METHODS 

We conducted this study as part of a mixed-
methods CBPR project, funded by the National 
Institute on Minority Health and Health 
Disparities (NIMHD/NIH). Details regarding the 

specific methodology of the larger study are 
described elsewhere (Salihu et al., 2015; Salihu et 
al., 2016; Salinas-Miranda et al., 2015; Salinas-
Miranda et al., 2017). We conducted this study 
within a targeted urban community that 
encompassed five zip codes in Hillsborough 
County, FL, USA. The community's estimated 
population was 110,451 in 2013 (U.S. Census 
Bureau, 2013). Neighborhoods within this 
targeted area are largely impoverished (U.S. 
Census Bureau, 2013; Florida Department of 
Health, 2013). Within the study area, the majority 
of residents are Black (60%), followed by White 
(18%), Hispanic/Latino (12%), and other (10%) 
(U.S. Census Bureau, 2013). At the start of the 
study, Hillsborough County’s Infant Mortality 
Rate (IMR) was 7.56 per 1,000 live births, 
(Florida Department of Health, 2013), above the 
Health People 2030 target of 5.0 infant deaths per 
1,000 live births. Infants born to Black mothers 
within Hillsborough County die at an IMR of 13.9. 
In contrast, the IMR for White babies is 5.5 
deaths per 1,000 live births (Florida Department 
of Health, 2013), demonstrating a disturbing 
Black-White disparity in IMR.  

This project built and expanded upon an existing 
15-year community-academic partnership
between REACHUP, Inc., and the University of
South Florida (USF) (Salihu et al., 2011).
REACHUP is a community-based, 501(c)3
nonprofit organization that provides healthy start
services and risk reduction services to mothers
and children. Prior CBPR collaborations between
USF and REACHUP have significantly reduced
preterm birth in the area by 30% (Alio et al., 2013;
Salihu et al., 2009; Salihu et al., 2011). We used
this successful CBPR platform to plan, implement,
analyze, and disseminate this project and created
a Community Advisory Board (CAB). The CAB
comprised eight active members in the target area
with a long history of grassroots development
work, who were well connected with various local
organizations. Many members were past CBPR
participants and therefore possessed expertise in
research activities (Alio et al., 2013; Salihu et al.,
2009; Salihu et al., 2011). They served as

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gatekeepers between the academic researchers 
and the larger community and represented the 
community’s racial/ethnic diversity. CAB 
volunteers took ownership of the study plan and 
protocol. They participated in bi-weekly face-to-
face CBPR trainings and discussion meetings to 
ensure methodological rigor and develop a shared 
vision of the research process. All CAB members 
completed a Human Subjects Protection 
Certification course. The study was approved by 
the USF Institutional Review Board (IRB) and the 
UF IRB. 

Trained community members conducted ten focus 
groups. CAB members recruited participants 
through word of mouth, email, flyers, social 
networks, and social media. We used purposive 
sampling, a sampling strategy used commonly in 
qualitative research that carefully selects 
participants based on their experiences, rather 
than random sampling.  

Purposive sampling was used to identify 
individuals who could provide insight into the 
community context (Krueger & Casey, 2000). 
Participants were selected based on the following 
criteria: residency of five years or more in any 
target ZIP code, interested in sharing views about 
mothers and infants in the community, female or 

male adults and children 12 years of 
age or older with parental consent, 
and able to speak English or Spanish. 

Individuals interested in 
participating in a focus group called 
the phone number provided in study 
flyers, and community research staff 
answered questions and provided 
study information. Informed consent 
was obtained, and $10 incentives 
were provided (an amount deemed 
acceptable and non-coercive). We 
monitored the participants’ 
sociodemographic characteristics to 
prevent overrepresentation in any 
particular subgroup. Focus groups 
were conducted in private rooms in 
designated community locations and 

held at times most convenient for participants.  

Trained community moderators facilitated the 
focus groups. Community co-moderators and 
graduate student volunteers at the USF College of 
Public Health enrolled in a CBPR doctoral-level 
course took detailed field notes. We used a semi-
structured questioning guide with questions 
developed with CAB members.  

The facilitators provided a summary of examples 
and asked for any additional feedback. We used 
probes when needed to encourage discussion. All 
focus groups were recorded with a tape recorder 
and transcribed verbatim, except for one focus 
group where we only took field notes. 
Transcription of each focus group was performed 
by a trained community member who was familiar 
with the local language. In order to maintain 
confidentiality, identifiable information was 
deleted from transcripts. 

Trained CAB members hand-coded paper-based 
transcripts, using flipcharts, sticky notes, and 
scissors (Krueger & Casey, 2000), facilitated by 
USF researchers during one of our bi-weekly 
meetings. Hand coding is a commonly used 
qualitative method signifying that coding was 
done through comprehensive review and re-

The Community Advisory Board (CAB) and academic researchers at a bi-weekly 
meeting, hand-coding the paper-based focus group transcripts. 

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review of transcripts and not using a computer 
program (Patton, 2002). We conducted 
exploratory thematic analysis (Sandelowski & 
Barroso, 2003) by reading the data while 
reflecting on study aims. We then coded 
meaningful categories by dividing CAB members 
into groups of two to three by focus group 
transcript and creating codes from the community 
perspective. We listed the categories and 
discussed them for contrast and comparison 
across focus group transcripts, which led to the 
identification of concurrent themes across focus 
groups (Sandelowski & Barroso, 2003). 
Illustrative quotes were selected to represent 
themes (Strauss & Corbin, 1998). Findings from 
early analyses were presented in two community 
forums to check for validation. These early 
findings also led to the creation of a community 
needs assessment survey (Salinas-Miranda et al., 
2015) and a community-based dietary 
intervention (Salihu et al., 2016). Risk factors 
were published in a separate article (Salinas-
Miranda et al., 2017). 

Two members of the research team then 
preserved written notes digitally with NVivo 
qualitative analysis computer software, including 
illustrative quotes (NVivo qualitative data analysis 
Software; QSR International Pty Ltd. Version 11, 
2015) to maintain a record of the analysis and to 
conduct conceptual/thematic descriptions 
(Sandelowski & Barroso, 2003). We used axial 
coding, an established qualitative data analysis 
technique of linking categories to subcategories 
and connecting categories at a higher conceptual 
level (Strauss & Corbin, 1998). This process 
involved coding and re-coding until agreement on 
the emerging themes was achieved by the CAB 
members and researchers (Strauss & Corbin, 
1998). From our themes, subthemes, and 
continuous coding and re-coding, hierarchical 
patterns developed, and we conceptualized a 
model based upon these relationships.  

RESULTS 

A total of 78 community residents participated in 
the focus groups. The distribution of focus groups 
was as follows: one focus group from each of the 
five target ZIP codes, one focus group comprising 
fathers only (mixed ZIP codes), two focus groups 
in Spanish for Spanish speakers (mixed ZIP 
codes), and two focus groups comprising 
adolescents (mixed ZIP codes). Table 1 presents 
the sociodemographic characteristics of 
participants. The majority of participants were 

Characteristics  % 

Age 

12-18 years of age 10.3 

19-40 years of age 46.1 

41 and older 43.6 

Gender 

Male 38.7 

Female 61.3 

Ethnicity 

Hispanic or Latino 20.5 

Not Hispanic or Latino 79.5 

Racial Categories 

American Indian/Alaska 
Native 

2.6 

Asian 2.6 

Native Hawaiian or Other 
Pacific Islander 

2.6 

Black or African American 61.5 

White 25.6 

More than One Race 5.1 

(N=78) 

Table 1  

Participant sociodemographics 

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adults. The two focus groups conducted with 
children 12 to 18 years of age represented 10.3% 
of the participants. The majority of participants 
were female (61%), non-Hispanic or Latino 
(80%), and Black (62%).  

Protective Factors 

Across focus groups, community residents 
mentioned several protective factors that 
frequently contribute to maternal and child 

health. We organized these factors as themes 
around three life periods, under the life course 
perspective: including factors affecting the health 
of children and adolescents, women in general 
(preconception period), and women during 
pregnancy. Some factors cut across life periods, 
whereas other factors were discussed with 
particular emphasis for one or two life stages. 
Within each life period, we identified constructs 
that fit within the broader themes of personal and 

family factors, health issues, and community and 
economic factors. We were also able to identify 
factors (Figure 1) that are more relevant for the 
different life periods based on community 
members' perspective and potential cumulative 
pathways of factors that may continue to exert 
their protective effects in a continuous manner. 

Protective factors that affect the health of 
children and adolescents  

Protective factors that affect the health of children 
and adolescents were identified and classified into 
subthemes such as self-esteem, positive role 
models, nutrition and healthy diet, physical 
activity and recreation, and community support. 
Quotes are presented in Table 2.  

Self-esteem was a protective factor that emerged 
throughout all the focus groups and across all 
genders/ages, having its origins in childhood and 
adolescence. Participants noted positive role 

Factors affecting 
Adolescents and Children 

Factors affecting 
Preconceptive Women 

Factors affecting Pregnant 
Women 

Pe
rs

on
al

 a
nd

 
Fa

m
ily

 F
ac

to
rs

 

} Self-esteem
} Positive role

models

} Self-esteem
} Spirituality
} Social support

} Self-esteem
} Spirituality
} Support during

pregnancy

H
ea

lth
 is

su
es

 } Nutrition and
healthy diet

} Physical activity
and recreation

} Health literacy } Good nutrition
} Prenatal care

C
om

m
un

ity
 

an
d 

Ec
on

om
ic

 
Fa

ct
or

s 

} Community
support

} Community support
} Community

resources
} Societal factors

} Community
resources

Figure 1 

Possible pathways of maternal and child health protective factors throughout the life course identified by 
community members 

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models in their lives and shared their positive 
experiences, which they recommended should be 

emulated through positive role models for 
children.  

Personal & Family Factors 

Self-Esteem  “Feeling good about yourself, having self-esteem.” 

Positive role models “My stepfather took me out in the yard on Saturday … the first thing he told me was, ‘Boy, keep you a rake and 
a lawnmower because the grass won’t never stop growing.’ And that was… You know, I was nine years old 
and right now today I own a tree service and landscaping service… I always remember, that’s why I renamed 
the business after my stepfather because he told me that… Don’t roll that weed, get a weed eater.”  

Health Issues 

Nutrition and Healthy Diet “My momma had me in the garden…to raise vegetables and … health foods and stuff, you know, organic type 
of stuff…And then that helps you, too, you know, environmentally. And then you have growin’ trees and stuff in 
your neighborhood and stuff like that. Plant a tree or something.” 

Physical activity and 
recreation 

“You know, there used to be a lot of after school programs at the parks and everything for the kids to go get 
involved in, even during the summer programs. But nowadays they done took away all those programs, now 
the kids don’t have nothing to do but walk around the street, then there’s nothing to do...But if you left those 
programs and you really implemented programs and encouraged those programs, the kids will become better 
kids, role models, that’s because the kids are the future.” 

“Creating programs within the community, where they can come and being a public role model without just 
listening to the music all the time. The education at the YMCA, you know, they have… teaching them on 
health... the kids don’t get that today. So mainly in the health issues, that’s what we’re lacking.” 

“I think children need to be involved in school activities. Like, if your daughter’s a cheerleader, you should find 
time to go and watch her as she’s cheering. Your son playing football or some type of sports. Because I go 
and volunteer at the high school concession stand, and the parents do not come to watch their kids. And right 
there is no support…Yes, there was only two high schools, but it was a community effort, you went and 
supported your child. And you had worked just as hard all day, and then you had to get a ride.” 

Community & Economic Factors 

Community Support 

“Yeah, the whole neighborhood raise them.” 

“Big Brothers, Big Sisters, United Way, and others. Well, really, to keep our teenagers staying healthy we just 
need a little help… Just like encourage them a lot and try to do what’s right and, you know, go by… I also think 
like the Big Brothers program or something like that, maybe finding like a role model, somebody that you 
personally know that your child looks up to this person and try to talk to them maybe behind the child’s back to 
say, hey, my child’s struggling with this, this and that, I’ve tried, you know, but he doesn’t or she doesn’t want 
to hear it from me, you know, could you help me out with this.” 

“The school system has placed some more emphasis on healthy teens or, you know, I would say that can be 
attributed to a lot of positives going on in the community.” 

“Exposing your kids. You can live in a rough neighborhood, like I grew up in…we went outside the 
neighborhood to museums. And I think a lots of time we stay within our community. But going outside and that 
really enlighten you. Expose your mind.” 

Table 2  

Protective factors that affect the health of children and adolescents 

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Some participants had specific family members or 
mentors that encouraged skills and motivated the 
individuals, while other participants commented 
on the importance of programs for children who 
may not have such positive role models. Programs 
such as Big Brothers, Big Sisters were mentioned 
frequently and praised by participants.  

A healthy diet was mentioned repeatedly as 
important for health, especially for children and 
adolescents. One participant discussed how her 
mother taught her to grow vegetables in a garden, 
which she described as leading to healthier eating. 
The theme of nutrition and a healthy diet does not 
exist in isolation, rather it is also related to the 
theme of positive role models. Participants 
stressed that parents have an essential role in the 
food their children eat and suggested a need to 
educate parents and families on the importance of 
a healthy diet and nutrition for health. Nutrition, 
physical activity, and recreation among children 
were perceived as very important, as indicated by 
the emphasis and rich examples provided. One 
participant noted how after-school programs were 
beneficial in helping kids with physical activity. 
However, participants noted that such programs 
are scarce within this community. Even though 
the lack of after school programs within this 
community is seen as a risk factor, participants 
indicated that physical activity and recreation are 
very important to youth and serve as protective 
factors. Participants stressed the need for creating 
community programs for physical activity and 
general health promotion among adolescents. 
These health promotion programs and programs 
that promote physical activity and recreation 
seemed to have existed more in the past, and the 
participants commented that such programs are 
missing nowadays.  

Participants also indicated the key role of parents 
in supporting children’s active living. For 
instance, one participant indicated that although 
kids may be involved in sports -- mentioned as 
protective to health -- parents often do not 
provide enough social support. Social support 
from parents was discussed as a protective factor 

that was also more present in the past but seems 
to be lacking today. Lastly, community resources 
for children and adolescents were described as the 
“it takes a village” (implying the need for many 
people’s involvement). One participant noted that 
there were community resources that could help 
parents establish better communication with their 
children. These resources are often underutilized, 
as depicted in Table 3. These resources could also 
provide solutions to barriers previously 
mentioned, such as the low number of parents 
who show up to their children’s sporting events. 
Another participant noted beneficial changes in 
the local school health system that may channel 
positive change in adolescents. These changes 
were connected to the previous theme of self-
esteem. On the other hand, participants 
recognized the need for accessing outside 
community resources to support children’s health. 
Although taking children to museums and other 
places outside of the community were described 
as protective factors, there was an emphasis on a 
need to bring more programs to the community.  

Protective factors that affect the health of 
women in general (preconception 
period) 

Subthemes identified for women in general  
offered a wider breadth of protective factors 
(Table 3), including spirituality, health literacy, 
community building, and societal factors in 
relation to race and ethnicity. Though this cohort 
offered unique subthemes, some subthemes were 
repeated, such as self-esteem and various forms of 
social support.  

The importance of spirituality and related 
practices (e.g., prayer) were mentioned frequently 
as protective factors for women. Participants 
indicated that the church has always been the 
center of the community, explaining that churches 
do a lot of good for the community. However, 
participants also emphasized that churches should 
work together more intensively to solve 
community problems, as many churches within  

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the community do not communicate and work 
with each other.  

Self-esteem was again mentioned as a protective 
factor that affects the health of women in general. 
Participants also emphasized the importance of 

Personal & Family Factors 

Spirituality 
“So, every day have some spiritual time with Him to read in that Bible.” 

“Prayer and support help you to stay healthy.” 
Self-Esteem  “You need to know how to come back, even though you fail, you need to know how to step back up.” 

Social Support 

“Support. Common support. Family support. You know, support from any and everybody.” 

“Like I say, it’s a big job cleaning the house up, keeping the house clean is a big job. And then we as men 
should recognize that and try to help our spouse, and I think that’s going to help. When you’re helping a woman 
and doing that, that going to make her love you more.” 

Health Issues 

Health Literacy 
"Being caught up-to-date, you know, through the clinics and stuff. The clinics giving out information about 
diseases and - you know- different type of sickness.” 

"If people are educated about health care and especially minorities because we’re at risk for so many things like 
high blood pressure and diabetes; and I think if people are educated about the dangers and what can happen to 
you with these diseases, then they’re more likely to take care of it. Preventive health care is another thing.” 

Community & Economic Factors 

Community 
resources and 
community 
building 
activities 

“I think that we should implement more opportunities in our neighborhoods for all of our people to come 
together, maybe a place of recreation for the whole community. I did hear one time about people having 
community garden where they got together and they, the little ones, the older ones, the ones in the middle, you 
know, everybody got a chance to participate and be proud of what they created which also brought unity to the 
community and people to know who each other were.” 

“We need to get to know each other again.” 

“They have a bus that does mammograms, they do blood pressure check, there’s a bus.” 

“I think going into the different neighborhoods at least once a month or once a week, letting them know this is 
available to you.” 

“Have like community outreach where you can come get… Because I know back in the day, if your baby needs 
shots, they’re like a Saturday or Sunday, you know, when I was a kid because my mom used to take us, the 
public housing would have on Saturdays where you could come in, get your baby shots, you know, get them 
checked for colds and, you know, different stuff like that. They don’t do that anymore.” 

Societal factors “I think it’s lack of opportunities, maybe how society sees the Black woman. And it shouldn’t be like that but it is. 
Because they’re made to…feel inferior but they don’t realize, if it wasn’t for a woman, we would have nobody to 
carry us…if we would concentrate on more opportunity, it could get a lot better… if you have more opportunity, 
you’ll get out of those things.” 

Table 3 

Protective factors that affect the health of women in general (preconception period) 

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resilience. Although self-esteem and resilience 
were noted as significant protective factors for 
women, participants emphasized a need to 
connect women with more mental health 
resources and other community programs that 
build self-esteem and resilience. Participants 
stated that there are many resources available but 
residents need to be made aware of these 
resources and connected to the appropriate 
programs. Several participants noted the 
protective role of social support from close 
relationships and other social connections. A male 
participant stressed the role of instrumental social 
support from men. Participants emphasized that 
adequate relationship support and support from 
family members and friends were critical 
protective factors that helped women reduce and 
manage stress.  

Focus group participants indicated the 
importance of health literacy as a protective 
factor. One female participant discussed being 
informed about her health as an important 
protective factor for women’s health. One female 
participant also pointed to the importance of 
community-tailored health education and its 
potential to prevent health problems in the 
community. Participants further elaborated that 
knowledge acquisition and the personal practices 
associated with information sharing were key 
determinants for a woman’s health. 

Participants talked about the importance of 
community building activities and community 
resources. Both a community garden and a 
community center were mentioned as important 
protective factors for health because they build 
community unity and a sense of togetherness. 
Even though these were seen as protective, many 
participants said that community gardens and 
community centers were lacking in this 
community and emphasized that creating 
opportunities for neighbors to come together 
would be protective through support and 
community unity. Participants also stressed the 
importance of community outreach programs and 
health fairs as protective. Some mentioned them 

as being abundant in the community and noted 
that community outreach is a strength of this 
community. Other participants indicated there is 
a need for more advertising and marketing of 
these events. Other participants mentioned a 
greater need for programs within this community 
and that programs like this used to exist but are 
less common today.  

Other participants mentioned societal factors, 
such as socioeconomic opportunities for Black 
women. When participants discussed social and 
economic opportunities for women in general, 
they focused on their absence and mentioned the 
need for more significant opportunities and 
changes to attitudes and stereotypes. In this 
regard, greater social inclusion of Black women, 
improved social and economic opportunities, 
positive attitudes toward Black communities, and 
the elimination of negative stereotypes are in line 
with strategies for healing racism and addressing 
historical trauma (Williams et al., 2019). Although 
not explicitly mentioned, these factors emerged 
from the conceptual analysis.   

Protective factors that affect health 
during pregnancy 

Protective factors for pregnant women echoed 
similar themes and subthemes as children and 
adolescents and preconception periods. However, 
there was a unique emphasis on spousal or 
partner support during this period in a woman’s 
life (Table 4).  

Self-esteem and positivity were mentioned as 
important protective factors that affect health 
during pregnancy. Participants described having a 
positive mental outlook and psychological well-
being as necessary. They talked about 
surrounding oneself with optimistic people, as 
positive role models, and accepting the pregnancy 
if you are going to have the baby. Another 
participant discussed the importance of setting 
personal goals. Residents emphasized the 
importance of remaining optimistic, even if the  

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Personal & Family Factors 
Self-Esteem and Positivity “Just hanging around positive people. Even if you are pregnant out of wedlock, don’t hang around 

someone who can always talk you down.” 

“Working hard for something. Having a goal in mind. Being focused on something.” 
Spirituality “You ought to remind the young woman that carrying the child is [to] read your Bible to your child 

every day. Read the Bible to her. That’s one of the key things I always tell them when I say take 
them vitamins, drink plenty of water …out loud so the baby can hear what you’re saying.” 

Support during 
pregnancy/Father support 

“Having a good support system. And, preferably if it’s the dad of that child.” 

“So she can have some time to herself. If it’s nothing but to take a nap or take a walk, she can 
have a few minutes to become just herself and not have to be a momma or this or that or 
whatever, she can just be herself and just have a few minutes. You know, and that’s what I can 
actually do to help somebody to be, you know, just to give her a chance to reset her mind. She 
need emotional support from her significant other or family members because whatever affect her 
will affect the baby.” 

“And for new mothers before they even have their babies…the support groups, where they can 
get together and they can talk about all of those things that they can do for their babies once they 
are born… I think that would be a really good requirement for pregnant women to have to go 
through something that where they would have some insight on what they’re going to… just to 
teach them what they are going to be facing. There should be a requirement for every pregnant 
mother to go through something like that, to just be aware of the changes that’s going to happen, 
the mother and the father as a matter of fact.” 

Health Issues 

Good nutrition “Eating right and eating properly” 

"I don’t know, but he may not understand it totally but he knows that a pregnant woman need to 
eat right.” 

Prenatal care “Taking your prenatal vitamins” and “Get the shots.” 

“Also, with women with the things that we can do is we can also… Well, what they can do to be 
healthy is make sure they follow through with their doctor appointments, make sure they take their 
medications, make sure that they eat well, and do… And we can pray that daddy steps in and 
gives her a hand, you know, if he don’t do nothing but rub her feet because they swollen up...” 

Community & Economic Factors 

Community resources "I feel that if they had somewhere to go where a pregnant…a bunch of them pregnant women can 
sit down and talk and be amongst themselves and talk about things and have a avenue where 
they can air out problems or get help with the children or the babies…you’re taking another step in 
your life, to prepare them… like a support group.” 

Table 4 

Protective factors that affect health during pregnancy 

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pregnancy was unplanned. For women in general, 
spirituality was mentioned as an important 
protective factor for pregnant women.  

The residents cited support from friends and 
family and the father as a protective factor for 
pregnant women. Community members indicated 
companionship is an essential social support 
aspect, and others suggested that instrumental 
and emotional support were also critical. Some 
participants also indicated specific formal support 
sources, such as pregnancy support groups and 
parenting education classes for new mothers. A 
support group like the one mentioned would 
provide various types of social support, including 
emotional and informational. It would also offer 
education and tools to help better care for babies. 

Participants noted the importance of adequate 
nutrition to protect against pregnancy 
complications. The importance of a healthy diet 
for pregnant women was frequently mentioned 
and often stated that a healthy diet helps pregnant 
women to “be their best” during gestation. One 
participant also noted the partners’ role in 
knowing what a healthy diet during pregnancy is, 
emphasizing the importance of nutrition as a 
protective factor for pregnant women. It also 
highlights the importance of social support, 
especially support for healthy eating. 

Residents noted the importance of keeping up 
prenatal care appointments recommendations. 
Participants indicated that partners could help 
women adhere to prenatal care measures. The 
help partners and other friends/family members 
provide to pregnant women to keep up with 
prenatal care emphasizes the importance of 
instrumental social support as a protective factor 
for pregnant women. 

Community members also highlighted several 
resources available in the community that women 
could access to get support and health-related 
resources (e.g., insurance and nutrition 
education). These community resources included 
churches, food banks, and programs for mothers 
and babies in the area that serve as protective for 

pregnant women. Although some participants 
mentioned the abundance of resources in this 
community as a community strength, others said 
these resources are lacking. Connecting with a 
support group to receive various types of social 
support and pregnancy education was also 
mentioned as protective for pregnant women 
under the community resources theme. 

DISCUSSION 

This study used a CBPR strategy of inquiry 
through focus groups and the LCP as the 
theoretical framework to examine community 
residents’ perspectives of maternal and child 
health protective factors. Our goal was to obtain a 
better understanding of how life protective factors 
contribute to the health of women and children in 
low-income neighborhoods and communities of 
color.  

Lu and Halfon (2003) first theorized the LCP, 
suggesting that disparities in birth outcomes are 
not only caused by pregnancy exposures, but by 
the cumulative exposure throughout the life 
course. In 2010, Lu and colleagues developed a 
12-part plan to reduce the disparities in birth 
outcomes using LCP (Lu et al., 2010). The LCP 
emphasizes that exposures may be particularly 
salient at critical time periods, with three periods 
identified (in utero, the first three years of life, 
adolescence) as critically important for social, 
behavioral, and biological development (Lu et al., 
2010). The LCP also posits that the broader 
community environment strongly affects health, 
emphasizes the importance of transitions all 
individuals experience throughout life and places 
particular emphasis on equity (Hellerstedt, 2013).

Our study found qualitative evidence for life 
course theory principles. Life span development 
was assessed through the perceptions of 
community residents, which provides views 
within the community context. However, our 
study is not a longitudinal account of the 
individual participants experiences. Instead, our 
questioning strategy specifically asked the 
participants’ views about the 

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factors that are perceived to be associated with 
well-being and health for three life span stages 
(mothers, children, and youth). By asking about 
their perceptions about health during life span 
stages, the participants reported their experiences 
within their community context. Thus, 
commonalities emerged across the lifespan stages 
such as social support. For each stage, the rich 
responses provided by the participants illustrate 
the importance of assessing health as a process 
and beyond the present immediate context.  

On the individual level, participants identified 
self-esteem as a protective factor throughout all 
life periods and positivity in specific life periods. 
The constructs of self-esteem and positivity are 
consistent with previously theorized protective 
factors of the LCP, including personal resiliency 
(Hellerstedt, 2013). Resilience is a set of skills 
that are reinforced by healthy relationships that 
allow individuals to cope in the face of adversity 
(McDonald et al., 2016). There is evidence that 
the influence of community social networks, 
social stressors, and personal resources all 
confluence to predict self-esteem among women 
(Woods et al., 1994). Self-esteem as a protective 
factor may also be eroded by exposure to 
traumatic experiences (Matheson et al., 2015). 
Improving self-esteem, fostering mental well-
being, increasing self-efficacy, and ultimately 
enhancing self-identity among women and 
children may be important untapped mechanisms 
to address maternal and child health disparities in 
communities of color 
(Matheson et al., 2015). Programs that increase 
self-esteem, positivity, and resiliency, especially 
among youth, would be an essential social 
investment to improve the overall health of 
communities, resulting in healthier mothers and 
babies (Lu & Halfon, 2003). 

One of the most salient life course theory 
principles illustrated by participants was the one 
related to Interconnected Lives/Linked Lives, 
which was depicted in several quotes that 
mentioned social support and community support 
for children, adolescents, and pregnant women. 
Notably, the importance of parents and 

community support is an illustration of the 
principle of Linked Lives, showing the 
interconnectedness of community residents 
during all three stages assessed. This notion of 
linked lives is contrasted to the narrow view of 
health and healthcare as a personal issue. 
Individual choices and personal resources are 
important (Agency principle, which explains the 
human capacity to make changes themselves and 
own the capacity to have resilience), but they are 
constrained by the social and historical context. 
Some examples of human agency noted by 
participants were the role of spirituality as a 
personal resource, as well as self-esteem. Those 
aspects were cited as health-promoting factors 
over the life course. However, one’s spiritual 
beliefs are also shaped to a certain extent by the 
cultural and historical background of 
communities (e.g. Black churches as sources of 
spiritual support during times of segregation).  

Self-esteem was a protective factor that emerged 
throughout all the focus groups and across all 
genders/ages, having its origins in childhood and 
adolescence. Participants noted positive role 
models in their lives and shared their positive 
experiences, which they recommended should be 
emulated through positive role models for 
children. Self-esteem is a self-concept construct 
that is also shaped by one’s identities (i.e., gender 
identity) within the cultural milieu of the 
community (Biro, 2006). However, the fact that it 
was mentioned across life stages is intriguing. We 
speculate that given that the majority of 
respondents were racial/ethnic minorities, it is 
possible that they have been exposed to 

We speculate that given that the 
majority of respondents were 

racial/ethnic minorities, it is possible 
that they have been exposed to 

discrimination and racism. Several 
studies indicate how racism (micro 

and macro aggressions) is associated 
with low self-esteem and 

hopelessness. 

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discrimination and racism. Several studies 
indicate how racism (micro and macro 
aggressions) is associated with low self-esteem 
and hopelessness. 

Conversely, the role of high self-esteem as a 
protective factor for ethnic minorities is 
understudied. A cross-sectional survey study by 
Fisher and colleagues (2017) found a protective 
effect of ethnic identity on youth substance use, 
mediated by self-esteem. More studies are needed 
to examine the relationship between self-esteem, 
ethnic identity, and health over the life course.  

Consistent with previously theorized relationship 
level LCP protective factors (Lu & Halfon, 2003; 
Hellerstedt, 2013), participants identified social 
support throughout all life periods, with 
participants identifying positive role models as 
important for children and adolescents and 
support during pregnancy, particularly father 
support, as necessary for pregnant women.  

On the community-level, and in accordance with 
previously theorized community-level LCP 
protective factors (Lu & Halfon, 2003; Hellerstedt, 
2013), the importance of prenatal care among 
pregnant women emerged as a protective factor. 
The LCP suggests “improving the quality of 
prenatal care” and “expanding healthcare access 
over the life course” (Lu et al., 2010). The LCP 
recognizes the significance of prenatal care to 
early fetal programming and optimal health over 
the lifespan (Lu & Halfon, 2003). However, the 
LCP emphasizes that prenatal care cannot reverse 
the effects of early life chronic social stressors and 
cumulative risk factors (Lu & Halfon, 2003). 
Prenatal interventions may better improve birth 
outcomes if they begin before conception, as a 
vital part of women’s health care during 
reproductive age and over the whole life course 
(Lu & Halfon, 2003). The LCP also suggests that 
eliminating disparities will involve not only 
improving individual medical care, but also build 
stronger communities that foster the health of 
women and children throughout their lives (Lu & 
Halfon, 2003). 

Community-level factors were mentioned as 
protective factors in all life stages (Lu & Halfon, 
2003; Hellerstedt, 2013). Participants highlighted 
several community resources available that 
women could access to get support and health-
related resources, such as churches, food banks, 
and programs for mothers and babies in the area. 
Participants also talked of the importance of 
community building activities and community 
resources, mentioning community gardens and 
community centers as critical protective factors 
because they build community unity, but noted 
that these programs were scarce. The LCP plan 
proposes strengthening social 
connectedness/capital and investing in 
community building and urban renewal. 
Community building must begin with economic 
development, infrastructure development, 
accessible and safe parks and recreational 
facilities, and political development (Lu et al., 
2010). 

Societal factors were mentioned to be protective, 
in accordance with previously theorized LCP 
societal factors (Lu & Halfon, 2003; Hellerstedt, 
2013). Participants noted a need to change 
stereotypical attitudes and the need for more 
significant opportunities for Black women. This 
finding highlights the need to address racism and 
mitigate associated risks, which is consistent with 
Nuru-Jeter (2009), in a study exploring 
childbearing Black women’s experiences with 
racism, Nuru-Jeter’s (2009) findings suggest that 
racism measures focus on the lasting impact of 
institutionalized, vicarious, and internalized 
racism on women’s experiences throughout their 
life. Our findings are also consistent with Pies et 

Greater social inclusion of Black 
women, improved social and economic 

opportunities, positive attitudes 
toward Black communities, and the 
elimination of negative stereotypes 

are in line with strategies for healing 
racism and addressing historical 

trauma. 

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al. (2012), who suggested focusing on social 
determinants, such as efforts to undo racism, that 
will continue into future generations (Pies et al., 
2012).  

Our study has several notable strengths. To our 
knowledge, this is one of the first studies that has 
combined the LCP as a theoretical framework with 
the strategy of CBRP, creating an LCP-CBPR 
hybridization to identify protective factors for 
optimal maternal and child health using 
community residents’ perspectives. Combining 
life course conceptualization with intimate 
community involvement has built a strong 
foundation, revealing how the target community 
perceives maternal and child health protective 
factors as leading to optimal health.  

Despite these strengths, our findings should be 
understood within certain limitations. Even 
though we utilized purposive sampling, selecting 
participants for their specific experiences, self-
selection bias may have been present because 
community residents who chose to participate in 
the focus groups may be more interested in this 
topic than those who did not participate. 
Additionally, using qualitative methods can 
provide insightful information concerning a 
specific topic and generate hypotheses, but it is 
difficult to generalize our results to other 
communities.  

Even though risk factors are described in a 
previously published article (Salinas-Miranda et 
al., 2017), to fully conceptualize the LCP, it is 
important to examine protective and risk factors 
simultaneously. This article only describes the 
protective factors that lead to optimal health. 

Some of our findings discuss protective factors 
that the participants identified as being protective, 
but that might not actually exist within this 
community. In this regard, the lack of protective 
factors may be considered as a risk with a 
detrimental effect on the community. Although 
this community may lack certain protective 
factors, the residents still identified these factors 
as protective to health, so we included them 
within these findings.  

Finally, this community is primarily comprised of 
socioeconomically disadvantaged residents of 
color; however, our study did not specifically 
target African American women. The CAB 
recommended that we query everyone in the 
community about their perspectives. We 
considered this a positive way to engage the entire 
community in a discussion about the health of 
mothers and babies. Our perception is that this 
strategy of asking everyone about MCH issues 
fostered a wider community engagement, as 
opposed to other approaches that only engage 
women or men. We recommend that future 
studies address African American women’s, 
male’s, and children’s/adolescents’ perceptions 
separately.  

We believe the current study has achieved an 
appropriate balance between community 
participation and rigor. We recommend that 
future studies capture the perspective of 
community residents in other localities, as our 
results are not generalizable and are context-
dependent (Oetzel et al., 2018). 

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