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Chapter 6. Early Collaboration for Adaptation: Addressing Depression in Low-Income New Mothers
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Chapter 6 Early Collaboration for Adaptation: Addressing Depression in Low-Income New Mothers Susan G. Pfefferle Ben Cooper Debbie Layton Sharon Rohrbach Numerous studies demonstrate that, in settings for the care of the medically underserved, evidence-based depression treatments are underused.– Locating mental health services in nonspecialty settings has the potential to increase access to services for underserved populations., This chapter describes collaboration by a university-based researcher and a nurse home visitation agency aimed at fitting depression treatment into a setting where new mothers who reside in economically disadvantaged neighborhoods receive services. The Nurses for Newborns Foundation (NFNF) provides services to economically disadvantaged mothers with children under the age of two. For this intervention, we focused on mothers living in the St. Louis metropolitan area. The majority of families living in poverty in St. Louis are African American. Although there are several effective treatments for depression, we chose problem-solving therapy (PST) for the intervention because it is not stigmatizing, is a brief treatment, and fits well with the mission of NFNF because it can empower women to take control over their own lives. It also has a history of use by non–mental health specialists. Originally, PST was developed from the problemsolving component of cognitive behavioral therapy. It uses everyday problems that individuals encounter (such as not having enough quiet time) to teach problem-solving skills related to symptoms of depression. The therapy uses seven steps, which are reviewed in each session. These steps take the client through the process of identifying problems related to depression and then breaking the problems down into manageable steps. We describe the initial collaborative process between researcher and agency for this project; collaboration between researcher and agency is ongoing. Including Susan G. Pfefferle, PhD, is a researcher in behavioral health at Abt Associates, Cambridge, Massachusetts . Ben Cooper, BA, MPH, is a statistical data analyst at Washington University, St. Louis. Debbie Layton, RN, is the director of nursing at the Nurses for Newborns Foundation, St. Louis. Sharon Rohrbach, RN, is the executive director of the Nurses for Newborns Foundation. Early Collaboration for Adaptation 65 depressed mothers as collaborators was beyond the scope of this study. We solicited feedback through qualitative interviews about the acceptability of PST to mothers. The description offered here is intended as a practical guide for researchers concerned with targeting work for treatment adaptation, including those for adapting the treatment to the setting, considering populations’ needs and preferences, and addressing organizational influences to ensure sustainability of interventions. We strove to be principled in our collaboration. The Collaboration In spring 2006, NFNF in St. Louis, Missouri, began screening for maternal depression , as was mandated by their Healthy Start contract. The nurses, however, were soon overwhelmed by the number of women who screened positive for depression but were unable to access treatment. Simultaneously, the research partner was looking for an agency partner with whom to conduct research about maternal depression. In August 2006, NFNF and the researcher began to design a study on the feasibility of co-locating depression treatment in nurse home visitations. In November 2006, we submitted a small grant to the Fahs-Beck Fund for Research and Experimentation. The grant was funded in January 2007. Shared decision making A team met on a bi-weekly basis to design and monitor progress of the work. Initial meetings were with the researcher and NFNF senior management and later progressed to a small working team at the agency. After the team identified the project’s needs and interests, it chose PST as the intervention with the greatest potential to address depression safely during home visitation. The team obtained funding for the PST feasibility study and had several meetings to address operational issues. These included pay for the nurses, development of research time sheets, applying for institutional review board (IRB) approval, training and supervision in PST, and ongoing support for the nurses. For delivery of the intervention, the team explored whether to tag PST onto the end of a regular home visit or whether to provide it during separate visits (ultimately leaving the decision to the nurse and mother). As the work progressed, a clinical team took shape, composed of the nurses providing the intervention, the director of nursing, and the researcher. The nurses were active participants in identifying obstacles as well as providing solutions. Meeting biweekly at the agency, the team reviewed and contributed to the adaptation of all study materials. Meetings were scheduled for the nurses’ convenience, and the nurses were...