Cultural Adaptation of the Mothers and Babies Intervention for Use in Tribal Communities.

OBJECTIVE: While one in five women may experience mood and anxiety disorders during pregnancy and postpartum, Indigenous identity increases that risk by 62%, especially among younger Indigenous women. The need for evidence-based perinatal mental health interventions that provide culturally relevant well-being perspectives and practices is critical to improving maternal, child, and community outcomes for Indigenous peoples, and reducing health inequities. METHODS: Through a collaboration between community maternal and child health professionals, intervention researchers, and a cultural consultant, our workgroup developed cultural adaptations to Mothers and Babies, an evidence-based perinatal depression prevention intervention. Applying a cultural interface model, the workgroup identified existing intervention content for surface adaptations, as well as deep, conceptual adaptations to incorporate traditional teachings into this evidence-based intervention. RESULTS: This collaboration developed a culturally adapted facilitator manual for intervention providers, including guidance for implementation and further adaptation to represent local tribal culture, and a culturally adapted participant workbook for Indigenous perinatal women that reflects cultural teachings and traditional practices to promote well-being for mother and baby. IMPLICATIONS: Committing to a culturally respectful process to adapt Mothers and Babies is likely to increase the reach of the intervention into Indigenous communities, reengage communities with cultural practice, improve health outcomes among parents, children, and the next generation's elders, and reduce disparities among Indigenous groups. Replication of this community-engaged process can further the science and understanding of cultural adaptations to evidence-based interventions, while also further reducing health inequities. Future steps include evaluating implementation of the culturally adapted intervention among tribal home visiting organizations.

Comparing the Effectiveness of Clinicians and Paraprofessionals to Reduce Disparities in Perinatal Depression via the Mothers and Babies Course: Protocol for a Cluster-Randomized Controlled Trial.

BACKGROUND: Postpartum depression is highly prevalent in low-income women and has significant health and mental health effects on mother and child. Home visiting (HV) programs provide services to large numbers of perinatal women in the United States and are a logical setting for delivering mental health services. Although there are interventions that reduce the risk of developing postpartum depression among low-income women, none have used nonhealth or nonmental health professionals as interventionists. OBJECTIVE: This study aimed to outline the protocol of a cluster randomized trial funded by the Patient-Centered Outcomes Research Institute that evaluates whether the Mothers and Babies (MB) group intervention, when led by paraprofessional home visitors, is more efficacious than usual care. It will also examine if MB, when led by home visitors, is not inferior to MB delivered by mental health professionals (MHPs). MB has previously demonstrated efficacy when delivered by MHPs, and pilot work indicated promising results using home visitors to deliver the intervention. METHODS: A cluster randomized trial is being conducted with 38 HV programs. Sixteen HV programs will deliver MB using MHPs, 16 will deliver MB using paraprofessional home visitors, and 6 will deliver usual HV services. The study employs a modified covariate-constrained randomization design at the site level. We anticipate recruiting 933 women aged ≥16 years enrolled in HV programs, who are 33 or more weeks' gestation and speak either English or Spanish. Women in the 2 intervention arms will receive the 6-session MB group intervention. Baseline, postintervention, 12-week postpartum, and 24-week postpartum assessments will be conducted to assess client outcomes. The primary outcome will be the change in Quick Inventory of Depressive Symptomatology Self-Report 16 scores from baseline to 24-week follow-up. Secondary outcomes associated with core MB content will also be examined. Semistructured interviews will be conducted with home visitors and MHPs who are group facilitators and 90 study participants to gain data on intervention successes and challenges. Analyses will proceed at the participant level. Primary analyses for depressive symptoms score at 24 weeks postpartum will involve a linear mixed model, controlling for baseline symptoms and other covariates, and random effects to account for clustering. RESULTS: We have recruited 838 women through the end of August 2018. Recruitment will be completed at the end of September 2018. CONCLUSIONS: There is considerable potential to disseminate MB to HV programs throughout the United States. Should our results demonstrate home visitor efficacy when compared with usual care and/ noninferiority between home visitors and MHPs in improving mental health outcomes, no additional financial resources would be required for the existing HV staff to implement MB. Should this study determine that home visitors are less effective than MHPs, we will generate more wide-scale evidence on MB effectiveness when led by MHPs. TRIAL REGISTRATION: ClinicalTrials.gov NCT02979444; https://clinicaltrials.gov/ct2/show/NCT02979444 (Archived by Webcite at http://www.webcitation.org/archive.php). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/11624.

Depression outcomes associated with an intervention implemented in employment training programs for low-income adolescents and young adults.

IMPORTANCE: Recent estimates indicate that 6.5 million adolescents and young adults in the United States are neither in school nor working. These youth have significant mental health concerns that require intervention. OBJECTIVE: To determine whether a mental health intervention, integrated into an employment training program that serves adolescents and young adults disconnected from school and work, can reduce depressive symptoms and improve engaged coping strategies. DESIGN, SETTING, AND PARTICIPANTS: A quasi-experimental study was conducted; 512 adolescents and young adults newly enrolling in one employment training program site were intervention participants, while 270 youth from a second program site were enrolled as controls. Participants were aged 16 to 23 years and not in foster care. Study recruitment took place from September 1, 2008, to May 31, 2011, with follow-up data collection occurring for 12 months after recruitment. Propensity score matching adjusted for observed baseline differences between the intervention and control groups. MAIN OUTCOMES AND MEASURES: Depressive symptoms measured on a Center for Epidemiologic Studies Depression Scale (CES-D) and engaged coping strategies. RESULTS: The mean age of participants was 19 years, 93.7% were African American, and 49.4% were male. Six- and 12-month follow-up rates were 61.0% (n = 477) and 56.8% (n = 444), respectively. Males in the intervention group with high baseline depressive symptoms exhibited a statistically significant decrease in depressive symptoms at 12 months (5.64-point reduction in CES-D score; 95% CI, -10.30 to -0.96; P = .02) compared with similar males in the control group. A dosage effect was observed at 12 months after the intervention, whereby males with greater intervention exposure showed greater improvement in depressive symptoms compared with similar males with lower intervention doses (effect on mean change in CES-D score, -3.37; 95% CI, -6.72 to -0.09; P = .049). Males and females in the intervention group were more likely than participants in the control group to increase their engaged coping skills, with statistically significant differences found for males (effect on mean change in CES-D score, 0.32; 95% CI, 0.14-0.50; P = .001) and females (effect on mean change in CES-D score, 0.19; 95% CI, 0.01-0.37; P = .047) at 12 months. CONCLUSIONS AND RELEVANCE: Given the growing number of adolescents and young adults using employment training programs and the mental health needs of this population, increased efforts should be made to deliver mental health interventions in these settings that usually focus primarily on academic and job skills. Ways to extend the effect of intervention for females and those with lower levels of depressive symptoms should be explored.

Parenting Needs of Urban, African American Fathers.

Fathers play a critical role in children's development; similarly, fatherhood positively affects men's health. Among the larger population of fathers relatively little is known about the parenting knowledge of urban, African American fathers. Focusing on urban, African American fathers, the objectives of this study were to (1) understand the primary sources from which fathers learn about parenting, (2) determine where and how fathers prefer to receive future parenting education, and (3) explore the information perceived as most valuable to fathers and how this compares with the recommended anticipatory guidance (Bright Futures-based) delivered during well visits. Five focus groups, with a total of 21 participants, were conducted with urban fathers at a community-based organization. Study eligibility included being more than 18 years old, English speaking, and having at least one child 0 to 5 years old. During the focus groups, fathers were asked where they received parenting information, how and where they preferred to receive parenting information, and what they thought about Bright Futures parenting guidelines. Fathers most commonly described receiving parenting information from their own relatives rather than from their child's health care provider. Most fathers preferred to learn parenting from a person rather than a technology-based source and expressed interest in learning more about parenting at community-based locations. Although fathers viewed health care providers' role as primarily teaching about physical health, they valued Bright Futures anticipatory guidance about parenting. Fathers valued learning about child rearing, health, and development. Augmenting physician counseling about Bright Futures with community-based parenting education may be beneficial for fathers.

Birth outcomes associated with receipt of group prenatal care among low-income Hispanic women.

INTRODUCTION: Although Hispanic women in the United States have preterm birth and low-birth-weight rates comparable to non-Hispanic white women, their rates fall short of 2010 Healthy People goals, with variability found across states. This study examined the effectiveness of the CenteringPregnancy group prenatal care model in reducing preterm birth and low-birth-weight rates for Hispanic women. METHODS: Pregnant Hispanic women at less than or equal to 20 weeks, gestation initiating prenatal care between January 2008 to July 2009 at 2 Palm Beach County, Florida, public health clinics selected either group or traditional prenatal care. Data on neonatal birth weight and gestational age were obtained through abstraction of Palm Beach County Health Department medical records. Records were abstracted for 97% of CenteringPregnancy (n = 150) and 94% of traditional care (n = 66) participants. RESULTS: A statistically significant difference was found in the percentage of women giving birth to preterm neonates (5% group prenatal care vs 13% traditional care; P= .04). There were no statistically significant differences in the percentage of women having a low-birth-weight neonate when group and traditional care participants were compared. DISCUSSION: The CenteringPregnancy model holds promise for improving the birth outcomes of Hispanic women. Future research should be conducted with larger sample sizes to replicate study findings using experimental designs and incorporating formal cost-effectiveness analyses.

The mental health needs of out-of-school adolescents and young adults: an intervention conducted in employment training programs, Baltimore, Maryland, 2007-2008.

INTRODUCTION: Despite the large number of adolescents and young adults in employment training programs, a population that has poorer health and greater health risk than similarly aged in-school peers, we are unaware of any health interventions that have been evaluated in this setting. The primary objective of our study was to evaluate changes in depressive symptoms, coping strategies, and receipt of mental health services among low-income African American adolescents and young adults receiving a mental health intervention integrated into an employment training program. METHODS: The intervention consisted of an on-site mental health clinician, a peer-led depression prevention intervention, and training sessions for employment training staff. A pretest-posttest design assessed depressive symptoms, coping strategies, and receipt of mental health services at baseline and 12-month follow-up. Complete baseline and follow-up data were available for 136 of 218 eligible participants. Most study participants were African American (98%); average age was 18.8 years. RESULTS: The intervention had no effect on depressive symptoms or coping strategies. The percentage of participants who used mental health services at follow-up increased, but not significantly. Age was associated with use of active and support-seeking coping strategies, whereas use of mental health services before program enrollment was associated with use of mental health services at follow-up. CONCLUSION: Alternative intervention strategies may be needed to decrease the severity of depressive symptoms and increase use of coping strategies among adolescents and young adults in employment training programs. Future research evaluating such interventions should use quasi-experimental or experimental designs to provide evidence of intervention effect.

Training for staff of an employment training program to promote mental health discussions and referrals with out-of-school youth, Baltimore, Maryland, 2007.

We examined whether mental health training for staff of an employment training program for out-of-school youth aged 16 to 22 years would increase mental health discussions and referrals. We reviewed case files of participants at 1 Baltimore program who enrolled 6 months before (n = 303) and after (n = 263) a 2-day training program. Chi-square analyses indicated increases in the percentage of participants with discussions (1% to 9%, χ(2) = 4.91, P < .05) and referrals (11% to 16%, χ(2) = 5.16, P < .05). Brief, intensive training increased mental health discussion and referrals among job training staff.

Factors associated with mental health services use among disconnected African-American young adult population.

Research related to mental health service use among vulnerable young adults is limited. This study used an expanded version of Andersen's Behavioral Model of Health Services Use to evaluate factors associated with the use of different types of mental health services among a sample of predominantly African-American 16-24 year olds (n = 500) in an employment training program in Baltimore City. Results indicated that participants were more likely to have received mental health services in correctional facilities than in community- or school-based contexts. Use of mental health services in correctional facilities was significantly greater among males, those less than 18 years, and those who experienced more stressful events. Findings illustrate the need to develop seamless mental health services for vulnerable young adults in multiple contexts, including the criminal justice system.

Health access and status of adolescents and young adults using youth employment and training programs in an urban environment.

PURPOSE: To describe the health status and access to healthcare of adolescents and young adults disconnected from traditional education and work settings. The health status of these disconnected youth is largely unknown, although it is suspected to be quite poor. Most information about the health of youth in the United States relies on school-based samples. METHOD: In-person interviews with 1037 adolescents and young adults (aged 16-24 years) enrolled in an employment and training program in Baltimore were used to measure access to health services and health status in four domains: violent behavior, mental health, substance use, and reproductive health. Differences in healthcare access and health status by age and gender were examined. In addition, youth in the employment and training sample are compared with Baltimore youth in school and of comparable ages, as measured by the Youth Risk Behavior Surveillance System. RESULTS: Nearly 50% of young adults in the employment and training program were found to lack health insurance, and about 20% reported a time when they needed medical care but did not receive it. Youth in the program exhibited notable health status concerns, often exceeding the risk prevalence of students in school. In particular, adolescents and young adults disconnected from traditional employment and work settings were more likely to be in physical fights, to smoke cigarettes, and to use marijuana than their in-school counterparts. In-school youth were more likely to have considered harming themselves and to have made a suicide plan in the last year. CONCLUSIONS: Given high levels of health risk among youth disconnected from traditional education and work settings, adolescent health providers must increasingly pay attention to integrating health promotion and disease prevention strategies into youth employment and training programs, where sizable numbers of these youth can be reached.

Engagement in paraprofessional home visitation: families' reasons for enrollment and program response to identified reasons.

Home visitation programs have exhibited modest impact in promoting maternal and child health outcomes; therefore, formative research is necessary to examine whether home visiting program models or actual implementation need to be modified. In particular, client engagement and retention have been identified as areas in which program implementation can be enhanced. This study assessed home visiting clients' reasons for entering home visiting programs and their perception of programs' response to these identified needs. We asked newly enrolled home visiting clients (n = 123) to identify reasons for entering their home visiting program, including their first and second most important reasons. The most frequently cited reasons for enrolling were wanting information about job training, completing one's education, keeping in good health during pregnancy, and learning about infant growth and development. Home visiting programs' response to clients' identified needs varied. Needs more closely related to home visiting program goals of providing parenting education and promoting prenatal health were most often met, whereas needs less closely related to program goals (e.g., life course needs such as information about job training or education) were less often met. Our findings suggest that home visiting programs in urban contexts should consider modifying their program protocols to better respond to employment- and education-related issues facing their clients.

Hispanic women's perceptions of patient-centeredness during prenatal care: a mixed-method study.

BACKGROUND: Assessing the quality of prenatal care received by Hispanic women is particularly important, given the rapidly growing Hispanic population in the United States. The purpose of this study was threefold: to assess the prevalence of Hispanic mothers who perceived their prenatal care to be patient-centered, to determine whether Hispanic mothers were less likely to perceive their prenatal care to be patient-centered than non-Hispanic mothers, and to better understand Hispanic women's perceptions of the patient-centeredness of their prenatal care. METHODS: Semistructured interviews were conducted with a proportionate, stratified random sample of 359 women initiating prenatal care in their first trimester and 68 women initiating prenatal care in their third trimester who delivered at 10 Palm Beach County, Florida, maternity hospitals between May and December 2003. Interviews assessed three aspects of patient-centered prenatal care using quantitative and qualitative methods. RESULTS: Hispanic mothers were less likely than non-Hispanic mothers to perceive that doctors and nurses treated them with respect during their prenatal care appointments (adjusted OR, 0.29; 95% CI, 0.10-0.86), and to perceive that office staff treated them with respect during their prenatal care appointments (adjusted OR, 0.29; 95% CI, 0.12-0.73). Hispanic mothers were more likely to experience language or communication problems than non-Hispanic mothers (adjusted OR, 3.30; 95% CI, 1.40-7.76). Qualitative analyses found that lack of patient-centered care limited Hispanic mothers' ability to understand information given during prenatal visits, ability to ask questions about their prenatal care, and desire to return for subsequent appointments. CONCLUSIONS: Hispanic women could benefit from prenatal care that is more culturally and linguistically competent as well as care that is responsive to the group's cultural norms. One recommendation is the use of group prenatal care, which encourages groups of women with similar gestational ages to articulate and discuss cultural norms and attitudes about pregnancy during structured prenatal care sessions.