Preventing Postpartum Depression in Immigrant Latinas

Postpartum depression (PPD)-i.e., depression in the first postnatal year-affects 10-20% of women and is associated with diminished functioning, impaired interpersonal relationships, decreased parenting self-efficacy and less responsive parenting. Immigrant Latinas living in the United States are disproportionately affected by PPD, with rates estimated between 30-42%. Hypothesized mechanisms for this excess risk include acculturative stress, high rates of trauma, poverty, discrimination, and limited social support. Unfortunately, PPD prevention and treatment is limited among immigrant Latinas due to structural and cultural factors including lack of insurance, competing demands, shortages of language-concordant providers, and stigma. These factors underscore not only the need for interventions to reach this population, but also the need to deliver interventions outside of traditional healthcare settings.

Mothers and Babies (MB) is a group-based cognitive-behavioral intervention designed to teach mood regulation skills to women at risk for PPD. Originally developed for women of Latin American descent, the United States Preventive Services Task Force recognized MB as one of the two most effective counseling interventions for PPD prevention, with moderate to large effects sizes found across a series of randomized controlled trials (RCTs). MB has shown consistent positive effects when delivered to women across different racial/ethnic groups, including immigrant Latinas. However, prior MB trials with immigrant Latinas have found variability in dosage received, resulting in weaker intervention effects for individuals less fully engaging with the intervention. Previous MB trials also did not explicitly address social determinants of health such as food insecurity that may mitigate intervention effects. Immigrant Latinas have found the group modality highly effective in decreasing isolation and expanding access to resources and social networks, thus suggesting a potential larger role for group intervention modalities to address key social determinants of health.

This R01 application builds on previous trials of the MB in-person group intervention with immigrant Latinas by examining the effectiveness and implementation of virtual delivery of MB ("Mothers and Babies Virtual Group"; MB-VG). No prior studies have examined the effectiveness of a virtual group-based intervention to prevent PPD. Virtual interventions have the potential to mitigate structural barriers to receipt of mental health services commonly experienced by immigrant Latinas, thereby enabling increased intervention dosage. Virtual platforms can also facilitate delivery of multidisciplinary content by off-site providers that address inter-related social determinants of health that may moderate intervention impact. As such, the Investigators developed and pilot-tested MB-VG, modifying content of the in-person MB group intervention for virtual delivery, incorporating content focused on social determinants of health and parenting delivered by external service providers, and incorporating text messages as an implementation strategy to reinforce intervention content and promote intervention engagement. Pilot testing with 30 immigrant Latinas enrolled in three family support centers (Judith P. Hoyer Early Learning Hubs, "Judy Centers") in Maryland demonstrated good feasibility and acceptability of MB-VG. Investigators also found small to medium effect sizes demonstrating MB-VG effectiveness in reducing depressive symptoms and parenting stress and improving self-efficacy to manage emotions. The investigators are now poised to test MB-VG in a rigorous RCT and propose to conduct a Type 1 Effectiveness-Implementation RCT that enrolls 300 perinatal women (150 MB-VG; 150 controls receiving usual family support services) from across 12 Judy Centers with the following Specific Aims:

Aim 1: To examine MB-VG effectiveness with perinatal immigrant Latinas at risk of PPD. Women receiving MB-VG will exhibit greater reductions in depressive symptoms (Hypothesis 1; H1), exhibit fewer cases of PPD (H2) and report increased parenting self-efficacy and responsiveness (H3) compared to control participants receiving usual family support services. Exploratory Aim: Amongst enrolled participants (n\~150) who have an older child aged 2.5-4.5 years, the study will examine whether the skills taught in MB-VG also promote less child dysregulation and greater child readiness for school.

Aim 2. To evaluate MB-VG implementation. To inform future intervention delivery and scalability, the study will assess key implementation outcomes. Guided by the RE-AIM framework, mixed methods will be employed (e.g., semi-structured interviews, survey data, and session audio-recordings) to assess MB-VG reach, adoption, implementation, and maintenance.

Aim 3. To examine contextual factors influencing MB-VG effectiveness and implementation. Guided by the Consolidated Framework for Implementation Research (CFIR), the study will measure contextual factors at the outer (e.g., participant needs/resources), inner (organizational characteristics), actors (facilitators), intervention and implementation process (virtual) levels via mixed methods.

• Behavioral activation [Time frame: We will examine change in behavioral activation between baseline and 6-month post-intervention follow-up]
• Decentering [Time frame: We will examine change in decentering between baseline and 6-month post-intervention follow-up]
• Social support [Time frame: We will examine change in social support between baseline and 6-month post-intervention follow-up]
• Mood management [Time frame: We will examine change in mood management between baseline and 6-month post-intervention follow-up]
• Anxiety symptoms [Time frame: We will examine change in anxiety symptoms between baseline and 6-month post-intervention follow-up]
• Perceived stress [Time frame: We will examine change in perceived stress between baseline and 6-month post-intervention follow-up]