Children’s Network Conference 2017
Dr. Kendra Flores-Carter DSW, ACSW
La Tanya Matthews, MSW
Ricardo Cruz, BA
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Presentation Overview
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Prevalence and Barriers
• Latina and Black Women
• Barriers/Concerns
NICU and Maternal Depression
• Bonding concerns after birth
• NICU impact on moms health
Enhancing Hospital MMH Care
• Relevance of Education in Hospital
• Multi-disciplinary Roles in Treatment
• ARMC Maternal Mental Health
Program
Questions and Discussions
POSTPARTUM DEPRESSION with
LATINO and BLACK WOMEN
By: Ricardo A. Cruz, CCS, BS
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Is Postpartum Depression (PPD) prevalent amongst Latino and
Black Women?
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• Yes, however, little research available.
• Most studies have focused on non Hispanic whites and Asian
women.
• 46.7% rate of mild to moderate PPD and 8.4% had severe
depression.
• Black women have a prevalence rate of 38%.
• Little to no studies on Black women and PPD
RESEARCH DISPARITY
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• “...Little is known about the rates of postpartum depression among
minority women, particularly Black, Hispanic and Native American
women, and in women of low socioeconomic status, and even less data is
available about ethnic differences in rates of all health diagnoses (Seplowitz
et al.)”.
• The onset and presentation of symptoms often vary among mothers
regardless of their race and ethnicity. Many mothers emphasized loving
their children despite experiences with depression (Gaynes et al., 2005) .
• The Centers for Disease Control and Prevention estimates that African
American and Hispanic mothers have the highest rates of postpartum
depression among all racial and ethnic groups (2008).
IMPORTANCE OF RESEARCH
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• “Largest and fastest growing ethnic minority group and will
become the predominant ethnic group by the year 2020. The U.S.
Census Bureau (2004) reported an increase in the Latino
population by more than 50% since 1990, from 22.4 million to 40.4
million. Of these, 19.7 million are Latinas, about half of whom are
of childbearing age (Le et al.).”
HOME HEALTH PERSPECTIVE
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• Medical vs. Behavior • More emphasis on Medical.
POST DISCHARGE FOLLOW UP
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• Studies suggest that “Newborn Behavioral Observations
conducted in hospital and home settings may be an efficient,
cost-effective, relationship-based method for reducing the
likelihood of PPD (Nugent et al.).”
• Nurse home visits improve maternal and infant interaction
and decrease severity of postpartum depression.
BREASTFEEDING: AN EXAMPLE
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• “Data indicate that women experiencing postpartum
depression are less likely than non-depressed women to
breastfeed (Leis et al.).”
• ”The highest risk was found among women who had planned
to breastfeed and had not gone on to breastfeed (Borra et al.).”
• Nurse home visits improve maternal and infant interaction and
decrease severity of postpartum depression.
REFERENCES
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Healthy Community
Borra, C., Iacovou, M., & Sevilla, A. (2015). New Evidence on Breastfeeding and Postpartum Depression: The Importance of
Understanding Women's Intentions. Maternal & Child Health Journal, 19(4), 897-907. doi:10.1007/s10995-014-1591-z
Gress-Smith, J., Luecken, L., Lemery-Chalfant, K., & Howe, R. (2012). Postpartum Depression Prevalence and Impact on Infant
Health, Weight, and Sleep in Low-Income and Ethnic Minority Women and Infants. Maternal & Child Health Journal, 16(4), 887-893.
doi:10.1007/s10995-011-0812-y
Horowitz, J. A., Murphy, C. A., Gregory, K., Wojcik, J., Pulcini, J., & Solon, L. (2013). Nurse home visits improve maternal/infant
interaction and decrease severity of postpartum depression. Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN,
42(3), 287-300. doi:10.1111/1552-6909.12038
Le, H., Lara, M. A., & Perry, D. F. (2008). Recruiting Latino women in the U.S. and women in Mexico in postpartum depression
prevention research. Archives Of Women's Mental Health, 11(2), 159-169. doi:10.1007/s00737-008-0009-6
Leis, J., Mendelson, T., Tandon, S., & Perry, D. (2009). A systematic review of home-based interventions to prevent and treat
postpartum depression. Archives Of Women's Mental Health, 12(1), 3-13. doi:10.1007/s00737-008-0039-0
Nugent, J. K., Bartlett, J. D., & Valim, C. (2014). Effects of an Infant-Focused Relationship-Based Hospital and Home Visiting
Intervention on Reducing Symptoms of Postpartum Maternal Depression. Infants & Young Children: An Interdisciplinary Journal Of
Early Childhood Intervention, 27(4), 292-304. doi:10.1097/IYC.0000000000000017
Seplowitz, R., Miller, H., Ostermeyer, B., Sangi-Haghpeykar, H., Silver, E., & Kunik, M. (2015). Utilization of Psychiatric Services by
Postpartum Women in a Predominantly Minority, Low-Socioeconomic-Status, Urban Population. Community Mental Health Journal,
51(3), 275-280. doi:10.1007/s10597-014-9808-6
When your child is admitted into the
Neonatal Intensive Care Unit
By: La Tanya M. Mathews, MSW
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OBJECTIVES
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Understanding the barriers to bonding with your infant during
a NICU admission
How the NICU impacts your emotional health
How I can help. What is my role?
AGENDA
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1st Impression
The Long Haul
Bonding
Let’s not forget about Dad
Something is not right
Recommendations
Discharge and Beyond
THE FIRST IMPRESSION
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Pregnancy – you bond with your baby from the time. Many times, we “just
hope for a healthy baby.” Many parents have no clue what the NICU is.
Admission into the NICU – Infants can be admitted to the Neonatal Intensive
Care Unit for a number of reasons, prematurity, mommy had diabetes,
substance abuse, genetics disorders or respiratory distress, etc. Having a baby
in the NICU is traumatic experience. 1
Dreams turned into Nightmares – A variety of emotions begin to set in.
Anxiety, guilt, fear, etc. They are natural responses to traumatic evets. They are
not a sign of weakness. They are healthy part of adapting and adjusting to
being your baby’s parents. 1
Introduction to the NICU – “From the intensity of the hospitalization to the
vulnerability of bringing your baby home, parents of babies who begin life
medically fragile often think, feel, and parent differently than parents whose
babies were full-term and healthy.” 2
How long does my baby have to be here – being honest with the parents
about time frames and looking at the baby’s progress. Looking forward to the future.
When I return to work – finding a balance, exhaustion, overwhelmed.
Signs and symptoms of depression – If you notice changes in your thoughts,
feelings or behaviors during or after your NICU experience, it can be difficult to tell
whether the changes represent a typical reaction or signal the development of a perinatal
mood or anxiety disorder. 2
Trust issues – From the time a mother, walks in the NICU, there are trust issues.
‘who is this taking care of My Baby?’ Communication is key between the staff and
parents. So that Parents can trust that this nurse has the experience to take care of this
baby. A mutual relationship can develop also, where “parents can tell the nurse
that you’re unsure of yourself. The nurse can give you support and practice you
need to become skilled at taking care of your baby.” 3
THE LONG HAUL
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BONDING
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First time holding
Negative touch
Skin-to-skin
Cares for the baby
Babies need fathers to be present. Physical contact benefits the
baby and it strengthen the father-baby bond.
Mothers need fathers to be present. If mothers are not able to be
in the NICU, they rely on dads to provide information, update
and to be with the baby.
Fathers and mothers are to be a team.
Staff should also check-in with the fathers to make sure they ok.
4
LET’s NOT FORGET ABOUT DAD
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SOMETHING IS NOT RIGHT
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Poor/No visitation
Social barriers – There are physical, logistical and medical
challenges that can trigger depression while your baby is in the
NICU.
Transportation
Distance
Poor support
Anxiety, anger, depression – “Understandably, the stress and
exhaustion of life in the NICU takes a very real toll on parents’
mental health. Parents of children who have a stay in the NICU are
at a greater risk for anxiety, depression, and post-traumatic stress
disorder, for month or even years to come.” 5
RECOMMENDATIONS
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Checking-in – Communication! Communication! Communication. Multi-disciplines involved
with parents during infant’s length of stay.
Counseling – When should you seek professional counseling…
You think it may help.
Your ability to cope with the situation is not improving and you feel stuck
You continue to find no joy in other parts of your life
You have trouble with your relationship with your partner or others close to you
You feel a parent support group isnt “quite enough”
You should talk to a professional counselor if:
You feel prolonged numbness or detachment
You continue to feel detached from your baby
You have trouble getting out or bed or starting your day
You feel unable to cope or manage your other responsibilities
You think about harming yourself or others
Your doctor or the hospital social worker can refer you to a counselor who understands the trauma
of having a baby in the NICU. Even just a couple of visits might give you the reassurance you need. 3
DISCHARGE AND BEYOND
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A study in 2013 measured risk factors and management
strategies in PPD mothers and NICU infants.
131 mothers were given the Edinburgh Postnatal
depression scale.
19.1% experienced PPD. As the infant stayed longer in
the NICU, the odds of PPD increased, then leveled off
and then decreased after being admitted 31 days or
more.
Recommendation was to screen mothers routinely and
treat aggressively. 6
DISCHARGE AND BEYOND Cont.
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Mothers with previous mental health disorder and experiencing
negative perceptions of self and infant at the NICU discharge were
at increased risk for depressive symptomatology 1 month post
discharge regardless of infant’s gestation age. Comprehensive
mental health assessment prior to discharge is essential to identify
women at risk and provide appropriate referral. 7
Screen mothers at their 6 week f/u
Also screen mother at infant’s pediatric appointments
Provide resources and insurance referrals
The Fourth Trimester & Loss
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Definition of the Fourth Trimester8
Stages of Grief
Grief and Loss vs. Maternal Mental Illness9
-Complicated to differentiate
-Just address it
• Grief starts at the here
-Trained staff to provide grief support9
• Walking out the hospital
-Provide parents with some tools to cope
• Time Limit?
-Reminders, triggers, hopes and dreams10
REFERENCES
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Healthy Community
1. “Is this normal? How the NICU Impacts Your Emotional Health.” Hand to Hold:
Fragile Babies. Strong Support. Http://handtohold.org. March 2015.
2. Best, Sarah LCSW. “I can’t seem to shake the emotions from my baby’s time in the
NICU. What can I do?” Managing the Stress of a Baby’s NICU Stay. The Seleni
Institute.
3. March of Dimes. “Becoming a parent in the NICU.” www.marchofdimes.org
4. Fisher, Duncan. “Fathers are needed in the NICU.” https://fatherhood.global
Dec. 2016
5. MacMillian, Amanda. “The Stress of Having a Baby in the NICU.” The Seleni
institute.
6. Vasa R, Eldeirawi K, Kuriakose VG, Nair GJ, Newsome C and Bates J,
“Postpartum depression in mother’s of infants in the neonatal intensive care unit: risk
factors and management strategies.” The Journal of Pediatrics. Aug. 2013.
7. Hawes, Kathleen PHD, Elisabeth McGowan, Melissa O'Donnell, Rishard Tucker,
Betty Vohr. “Social Emotional Factors Increase Risk of Postpartum Depression in
Mothers of Preterm Infants.” The Journal of Pediatrics. December 2016.
8. The Fourth Trimester: What you should know about life postpartum. Deborah
Bohn . 2012. Https://www.babble.com
9. Grief and Bereavement Education and Support. CHOC Children’s Hospital.
Http://www.choc.org
10. Wender, Esther. MD. “Supporting the Family After the Death of a Child.”
Pediatrics. December 2012, Volume 130/issue 6
REFERENCES Cont.
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Enhancing Maternal Mental Health Care in a Primary Care Setting
Children’s Network Conference 2017
Dr. Kendra Flores-Carter
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Scope of the problem-Creates Health Concerns for Fetus/Infant
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Untreated Depression
Cognitive Difficulties
Poor Social Adaptations
Decreased Emotional Regulation
What to look for with our Pregnant Patients?
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Symptoms
Insomnia Hypersomnia
Weight loss/gain
Change in
Appetite
Poor Concentration
Worry Fear
Anxiety Mood
Swings
Sadness Crying
Helplessness Hopelessness
Guilt Suicidal Ideation
Understanding the Significance of this Public Health Concern
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Prevalence
PPD 1 in 7
13%-19%
Psychosis 1%-2%
Maternal Death by Suicide
10%
Infanticide 4%
Black Women
38%
Depression and Stress
Pre-eclampsia/Hypertension
Gestational Diabetes
NICU Infant
Pre-Term Birth
• High prevalence among AA
women
Pregnancy and Health Concerns
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Multi-disciplinary Roles in
Maternal Mental Health
Primary Care Approach
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NURSES
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• Nurses make up a large part of the primary care workforce in a primary care
setting such a hospital.
• Have a commitment to make decisions about patient care.
• A Study done by Hardy (2015) found that training nurses in mental health and well-being has the potential to improve integration of delivery of care for patients.
• Provide good quality physical health care to people with mental health problems, increase identification of patients with mental health concerns, enhance health outcomes, quality of life and patients experience of care.
Hardy, S. A., & Kingsnorth, R. (2015). Mental health nurses can increase capability and capacity in primary care by educating practice nurses: an evaluation of an education program in England. Journal of Psychiatric and
Mental Health Nursing, 22(4), 270-277.
PHYSICIANS
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• Physicians (OBGYNs, Pediatricians) act as gatekeepers.
• Monitor what happens overtime during prenatal care check-ups. • Notice if they are changes in mood document and review patient charts.
• The early discovery of potential problems allows physician to treat vulnerabilities
accordingly (Consulting Appropriate Specialist). • Doing so could potentially reduce moms symptoms of depression and other
health concerning issues. • Enables patients to have healthier and more happier pregnancy experience.
• Women with maternal mental health concerns receive extremely low levels of
preventive health care. • Are at risk of receiving inadequate and delayed prenatal care even when
controlling for known pregnancy related risk factors.
Byrd RS, Hoekelman RA, Auinger P. Adherence to AAP guidelines for well-child care under managed care. American Academy of Pediatrics. Pediatrics. 1999; 104(3 Pt 1):536–540.Salsberry PJ, Chipps E, Kennedy C.
Use of general medical services among Medicaid patients with severe and persistent mental illness. Psychiatric Services. 2005; 56(4):458–462.Howard LM. Fertility and pregnancy in women with psychotic disorders.
European Journal of Obstetrics & Gynecology and Reproductive Biology. 2005; 119(1):3–10.Kim HG, Mandell M, Crandall C, et al. Antenatal psychiatric illness and adequacy of prenatal care in an ethnically diverse
inner-city obstetric population. Archives of Women’s Mental Health. 2006; 9:103–107.
CLINICAL SOCIAL WORKERS
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• Clinical social workers perform assessments, arrange and develop services.
• Serve as gatekeepers to treatment providers (Gibelman & Schervish, 1996).
• Clinical Social Workers perform the largest portion of psychotherapeutic work done
in the United States (Hartman, 1994).
• Clinical Social Workers provide as much as 65% of all psychotherapy and mental
health services (Gibelman & Schervish, 1997).
• Assessment, Referrals/Resources, Collaboration with the MDT, Education to family.
Support network, Appointments, Home Health Care.
Gibelman, M., & Schervish, P. H. (1996). The private practice of social work: Current trends and projected scenarios in a managed care environment. Clinical Social Work Journal, 24, 323-338. Gibelman, M., &
Schervish, P. H. (1997). Who we are: A second look. Washington, DC: NASW Press. Hartman, A. (1994). The winds of change. Smith College Studies in Social Work, 64, 211-220.
Barriers To Seeking Services
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Approaches to Barriers
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• Services
• Some Services should be FREE
• Poor/Low Income Population
• Significant Logistical Barriers
• Lack of Support
• Working with Families to Identify Support within their Communities
• Educating Spouses and Additional Family Members on the importance of being
there for their loved one.
• Interventions
• Culturally Sensitive Interventions
• Interventions that are Brief, Effective, Easily Accessible
Treatment Options for MMH
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Cognitive Behavior Therapy
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• Standard treatment of depressive, anxiety, and stress and adjustment disorders
• Often includes pharmacological treatment and/or different types of
psychotherapy.
• CBT is an effective way of treating depressive disorders.
• Reconstructing thoughts
• Motivational Interviewing
• Strengths Based
• CBT is the most studied psychotherapy for depression, and thus have the greatest
weight of evidence
Oei TP, Bullbeck K, Campbell JM. Cognitive change process during group cognitive behaviour therapy for depression. J Affect Disord 2006; 92: 231–41.
Cuijpers P, Berking M, Andersson G, Quigley L, Kleiboer A, Dobson KS. A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Can J Psychiatry 2013; 58: 376–85.
Mindfulness Based Interventions
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• An important advantage of mindfulness-based therapies over most other psychotherapies is that mindfulness may be
accessible to larger groups of patients.
• After introduction.
• Patients could potentially practice mindfulness on their own.
• Mindfulness-based therapies decrease depressive symptoms and anxiety and reduce psychological distress.
• Evidence Based
• Mindfulness practices have is associated with less physical illness, improved well-being, increased self-control, decreased
negative affect, better affect tolerance and improved concentration, focus attention and working memory.
• A large number of studies suggest mindfulness-based interventions (MBIs) such as Mindfulness-based stress reduction
(Kabat-Zinn 2003) and Mindfulness-based cognitive therapy (Segal et al. 2002) are effective psychological interventions to
reduce depression and anxiety in clinical and non-clinical populations (Kuyken et al. 2015).
• There is also evidence that yoga practice in pregnancy reduces perinatal anxiety and depression (Newham et al. 2014).
• Non-pharmacologic interventions in pregnancy such as MBIs share overlapping common characteristics such as
meditation and regulated breathing. Davis DM, Hayes JA. What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy 2011; 48: 198–208.Kabat-Zinn, J. (2003). Mindfulness-based interventions in context:
past,present, and future. Clinical Psychology: Science and Practice, 10(2), 144–156.Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D.,Lewis, G.,Watkins, E., Brejcha, C., Cardy, J., & Causley, A.
(2015). Effectiveness and cost-effectiveness of mindfulness-based cognitivetherapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised
controlled trial. The Lancet, 386(9988), 63–73.Newham, J. J.,Wittkowski, A., Hurley, J., Aplin, J. D., &Westwood, M.(2014). Effects of antenatal yoga on maternal anxiety and depression: a randomized controlled trial. Depression and Anxiety, 31(8), 631–640.Segal, Z. V., Teasdale, J. D., Williams, J. M. G., & Gemar, M. C. (2002).The mindfulness-based cognitive therapy adherence scale: Inter-raterreliability,
adherence to protocol and treatment distinctiveness. ClinicalPsychology & Psychotherapy, 9, 131–138. http://dx.doi.org/10.1002/cpp
.320
ARMC Maternal Mental Health
Program
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• We recognized the need for Education
• Trained our nurses on the signs and
symptoms of depression
• Educate Patients
• We recognized the need for Support
• Developed an in-house support group
for families
• We recognized the need for Resources
• Through partnership with Children’s
Network we are able to provide
educational materials (Brochures) to
all our moms.
| 40 Needs Assessment and Implementing MMH Program
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• On average there are 300 births monthly at ARMC. Statistics note that one in seven women will experience PPD after giving birth.
• Placing roughly 42 women per month who have given birth at ARMC at risk.
• Approximately 50 percent of these women will not seek help.
• Mainly because they lack knowledge of post-partum depression.
• How to recognize the signs and symptoms.
• Stigma surrounding mental illness.
• ARMC’s Women’s Health Department developed a Maternal Wellness Education and Support Program to bring more awareness, education, support and resources to our patients. We saw a need and our goal was to meet that need.
| 41 ARMC Women’s Health Department
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• All mothers receive the Children’s Network “You Are Not Alone Brochure”
highlighting signs and symptoms of PPD in their hospital admissions packet
• A “You Are Not Alone” DVD PSA, developed by Children’s Network, is placed in
the ARMC TIGR system for mothers to watch prior to discharge as a way to
reinforce psycho-education about PPD.
• Posters are in every single women’s health clinic rooms highlighting signs and
symptoms of PPD and ways to seek help.
• Monthly PPD Support Group
• Every third Tuesday from 11 a.m. to Noon at ARMC
• Breastfeeding mothers are welcome to bring their babies.
• Both mothers and fathers.
| 42 Maternal Wellness Education and Support Program
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Intervention Research
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H1
• Viewing the “You Are Not Alone”
video intervention will increase Black
women’s knowledge of Postpartum
Depression.
H2
• Viewing the “You Are Not Alone”
video intervention positively
influence Black women’s Attitudes
towards Seeking Mental Health
Services.
| 44 Research Hypotheses
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| 45 Intervention “You Are Not Alone”
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https://www.youtube.com/watch?v=UC5Yfa5SvAY&t=5s
Design
• Pre-test/post-test
Sample:
• Convenience sample (N = 43) at
the Inland Empire Medical
Center located in CA.
Age:
• 18 and over
Race/Gender:
• Black Pregnant and Postpartum
female
Language:
• English
| 46 Methods
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• Fliers were placed on bulletin
boards
• Consents and survey data collected
in private rooms
• All subjects were notified that study
was voluntary and they could
withdraw at any time.
• All data kept in locked file cabinet
• Consent forms mailed to Chair at
UTK and secured in locked file
cabinet to maintain confidentiality.
| 47 Data Collection
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Age: 81% ranged from 18 to 30 years of age
19% ranged from age 31-40
Marriage: 79% were single or never been
married,
Education: 49% had some college
Employment: 72% were unemployed
Welfare: Almost all participants were enrolled in
WIC program or the combination of WIC and
other welfare benefit programs (70%),
Income: 76% monthly income ranged from $0-
$1500.
Mental Illness: 5% bipolar disorder, 2%
obsessive compulsive disorder, 2% schizophrenia
and bipolar.
Depression: 12% depression, 5% had been
diagnosed with postpartum depression
| 48 Findings
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The responses to each knowledge question were grouped into two categories correct or incorrect
responses.
The participants’ pre and post-test knowledge findings are reflected in Table 2.
| 49 Findings
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• To test the hypothesis that viewing the “You
Are Not Alone” video intervention would
increase knowledge with Black women
• A paired sample t-test was conducted.
• The hypothesis was found statistically
significant (p < .001) in that the “You Are Not
Alone” video intervention increased the
knowledge of PPD among the subjects.
• Failed to reject hypothesis
| 50 Findings
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51
| 51
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Discussion/Findings
The “You Are Not Alone” video
intervention increased the knowledge of
PPD among the subjects (Feasible
Intervention).
The “You Are Not Alone” video
intervention did not influence subjects’
attitudes towards seeking mental health
services for postpartum depression.
The apparent lack of influence on
women’s attitudes may be due to
participants being emotionally salient.
Many mothers did not have a history of
mental illness and may have perceived
the questions as none relatable.
????????
?
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